Provider Name: JEFFERSON COMMUNITY HEALTH & LIFE GARDENSIDE
Address: 2200 NORTH H STREET, FAIRBURY, NE 68352
Phone: (402) 729-5220
County: Jefferson (470)
Ownership Type: Non profit - Corporation
Certified Beds: 39
Average Residents Per Day: 28.9 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: JEFFERSON COMMUNITY HEALTH CENTER INC
First Approved Date: October 1, 2009
Affiliated Entity: ()
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 5 ()
QM Rating: 4 ()
Long Stay QM Rating: 4 ()
Short Stay QM Rating: (2)
Staffing Rating: 4 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.80286, LPN Staff Hours Per Day: 0.7870, RN Staff Hours Per Day: 0.5720, Licensed Staff Hours Per Day: 1.3591
Total Nurse Staff Hours Per Day, per resident: 4.16199
Weekend Nurse Staff Hours: 3.74246, Weekend RN Staff Hours: 0.4090
PT Staff Hours Per Day, per resident: 0.0222
Nurse Staff Turnover: 42.1, Nurse Turnover Note:
RN Turnover: 42.9, RN Turnover Note:
Admin Left Number: , Admin Turnover Note: 6
Case Mix Nurse Aide Hours Per Day, per resident: 2.0071, Case Mix LPN Hours Per Day: 0.6213, Case Mix RN Hours Per Day: 0.2778
Adjusted Nurse Aide Hours Per Day, per resident: 2.84492, Adjusted LPN Hours Per Day: 0.9347, Adjusted RN Hours Per Day: 0.7758
Total Adjusted Nurse Hours Per Day, per resident: 4.51388
Adjusted Weekend Nurse Hours Per Day, per resident: 4.05888
Health Survey Dates and Scores: Cycle 1: 2023-12-21 (Score: 8), Cycle 2: 2023-01-05 (Score: 0), Cycle 3: 2021-09-16 (Score: 44)
Total Weighted Health Score: 11.333
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations:
Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 3900.00, Payment Denials Number: 0, Total Penalties Number: 2
Location and GPS: 2200 NORTH H STREET,FAIRBURY,NE,68352 (40.1556, -97.176)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-01-15
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-01-31
Type: Health, Deficiency: Honor the resident's right to choose his or her attending physician.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-20
Type: Health, Deficiency: Post nurse staffing information every day.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-20
Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-20
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-20
Type: Health, Deficiency: Implement a program that monitors antibiotic use.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-20
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-20
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0131, Version: New
Description: Meet requirements for sections of health care facilities separated by fire resistive construction.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-01-05
Type: Fire Safety, Tag: 0132, Version: New
Description: Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-02-18
Type: Fire Safety, Tag: 0712, Version: New
Description: Have simulated fire drills held at unexpected times.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-01-04
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-01
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-01
Type: Fire Safety, Tag: 0362, Version: New
Description: Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-02-01
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-20
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-15