Jefferson House Memory Care Community

Deficiencies previously noted were corrected.

Facility failed to ensure safe food practices in the main kitchen, including lack of monitoring for sanitizing solution effectiveness and dishwasher wash/rinse temperatures.

Facility failed to ensure 2 of 6 staff members (Staff B and Staff D) were screened for tuberculosis within three days of employment.

Deficiencies previously noted were corrected.

Facility failed to complete Washington State Name and Date of Birth background checks for 2 of 6 staff members (Staff E and Staff F).

Facility failed to implement safe nursing services when a non-licensed staff member flushed a urinary catheter for Resident 3.

The facility failed to post the most recent full inspection report in a clearly visible area of the facility.

Deficiencies previously noted were corrected.

Staff E had expired CPR/first aid training and had not completed required 12 hours of continuing education.

Facility failed to ensure Resident 5 and family representative were given the opportunity to exercise rights regarding rearranging the resident's occupied room.

The licensee failed to ensure two residents' service agreements were updated to meet current and changing needs and to include care staff instructions and interventions. This was a previously cited uncorrected deficiency.

The facility failed to assess the safe use of equipment (Hoyer lift and tilt-in-space wheelchair) for one resident and failed to conduct change of condition assessments for two residents with pressure injuries.

Less than three foot working space around electrical panel in Electrical Room third floor.

Power adapter needs over current protection in Activity Director office.

Facility failed to provide documentation for semi-annual hood cleaning.

Kitchen stove grease trap full with accumulation.

Kitchen oven appliance not tethered to the wall.

Fire rated door from the staff lounge to the corridor was propped open with a door wedge.

Fire rated cross corridor door did not close or latch from the fully open position near room 308.

The walk-in type cooler and freezer with automatic defrost has ordinary temperature heads installed.

Facility failed to provide documentation for kitchen suppression semi-annual servicing.

Missing delayed exit sign near post office and missing instructions for delayed egress near room 307.

Door code not posted within six feet in main entry.

Facility unable to provide documentation for 12 planned and unannounced fire drills in the previous 12 months; previous logs missing employee participation records.

Facility unable to provide record of annual fire wall inspection and/or repairs.

Facility unable to provide documentation for fire/smoke damper testing; report lacked damper count or location.

Facility unable to provide documentation for annual sprinkler servicing (3-year full flow trip), quarterly servicing, and forward flow test.

Facility unable to provide service reports for the kitchen suppression system for the past 12 months.

No documentation of 90-minute annual testing performed in the last 12 months.

Facility missing documentation for annual generator service, weekly visual inspections, and 30-minute monthly load tests.

Facility unable to provide documentation for consistent monthly fire extinguisher inspections.

Missing inventory records for annual fire-rated door inspections; multiple doors found with excessive gaps or failure to latch/close properly.

Unsecured oxygen cylinder observed in the room next to the 3rd floor nurses station.

Facility has plastic ash tray containers in the smoking area.

Smoking area has cigarette butts discarded in the brush.

Fire drill logs missing records of employees participating in some drills.

Unable to provide documentation for last fire/smoke damper testing.

Unable to provide documentation for 30-second monthly testing of exit signs.

Unable to produce documentation showing fire extinguishers were inspected on a monthly basis.

Unable to provide documentation for annual and semi-annual hood cleaning.

Missing documentation for annual sprinkler service, 5-year internal pipe testing, 5-year FDC testing, quarterly sprinkler servicing, and forward flow test.

Unable to provide documentation for 90-minute annual testing of exit signs.

Missing annual fire door inventory; multiple doors have excessive gaps or fail to latch properly.

Unable to provide record of annual fire-resistant-rated wall inspection/repairs.

Unable to provide service reports for annual and semi-annual kitchen suppression system maintenance.

Missing annual generator service records, weekly visual inspections, and monthly load tests.

Facility was not able to provide documentation for the completion of twelve planned and unannounced fire drills in the previous 12 months.

Electrical room (1st floor) has unsealed conduits; Laundry room (1st floor) is missing a ceiling tile.

Unable to provide record of annual fire alarm system inspection/testing.

Unsecured oxygen cylinder in the room next to the Med room (3rd floor).

Facility failed to ensure 36 of 36 residents resided in a safe environment approved by the State Fire Marshal, with multiple fire safety violations noted in an 08/20/2024 report.

The facility failed to notify the physician and resident representative of a significant change in condition regarding a resident's significant weight loss (approx 73 lbs) over six months.

Facility failed to ensure 3 of 6 staff completed required training, including orientation, safety, basic training, CPR, and first aid.

First aid supplies were not readily available/locked, and the disaster plan lacked information on staff responsibilities, alternative accommodations, and communication plans.

Facility failed to document care needs related to a specific diagnosis and failed to provide documentation instructing staff on residents' baseline condition and monitoring for changes in cognitive functioning.

Facility failed to retain medication administration records (MARs) for 16 of 16 residents on the third floor, leaving only May and June 2024 records.

Facility failed to ensure 2 of 6 staff were screened for TB within three days of hire.

Facility could not locate the Medicaid Statement of Understanding for two sampled residents.

Facility failed to ensure 9 of 9 rooms tested provided adequate air flow and ventilation to the outside.

Facility failed to document in 3 of 7 sampled residents' (Resident 2, Resident 3, and Resident 7) Negotiated Service Agreement the care needs, interventions, and safety plans for medications with blood-thinning properties.

Facility failed to complete a character, competence, and suitability (CCS) review for 1 of 7 sampled staff (Staff G).

Facility failed to ensure 2 of 3 residents or their representatives signed the current service plan.

Facility failed to implement infection control policies (transmission-based precautions, respiratory protection program/fit testing, and laundry handling) for all 39 residents.

Facility failed to place a copy of the last full licensing report in a common area accessible to the public.