Jefferson House Memory Care Community

This fire safety inspection identified 11 violations spanning electrical safety, fire suppression systems, and life safety egress requirements. Key issues included blocked fire-rated doors, malfunctioning egress systems, missing documentation for required hood and suppression system servicing, electrical clearance violations, and improper sprinkler heads in coolers. The facility was disapproved following the inspection, and no evidence of corrective actions or facility response is documented in this report, indicating the violations remain unaddressed at the time of documentation.

The facility failed its second consecutive fire marshal inspection, leaving all 36 memory care residents in an environment with unresolved fire safety violations for an extended period. While the facility acknowledged the violations and reported working to correct deficiencies between inspections, they remained out of compliance at the time of the September 2024 investigation, demonstrating an inadequate pace of remediation. The facility cooperated with investigators and the maintenance director notified the fire marshal of corrections, but the prolonged non-compliance with life-safety systems in a memory care setting represents a serious systemic failure with high potential for catastrophic harm to a vulnerable population.

Jefferson House Memory Care Community has demonstrated systemic and persistent fire and life safety code violations across three consecutive inspections (July, August, October 2024). Critical deficiencies include missing documentation for sprinkler system maintenance, fire alarm testing, emergency generator inspections, fire door annual inspections, required fire drills, and multiple fire-rated door failures that did not close/latch properly. The facility's response has been inadequate, with the same violations repeatedly cited across all three re-inspections and minimal corrective action taken, resulting in continued 'Disapproved' status and only a few items marked as 'Corrected' despite multiple opportunities to remediate.

The facility failed to notify the physician and resident representative for six months (August 2023 - February 2024) as a resident experienced significant weight loss from 237 lbs to 164 lbs, violating coordination of care requirements. This delayed notification placed the resident at risk of medical decline and diminished quality of life. The facility conducted an investigation, acknowledged the violation, and implemented corrective measures including policy reinforcement and staff training, with a follow-up inspection on 09/06/2024 confirming all deficiencies were corrected. The initial failure to follow established protocols was serious, but the facility's subsequent cooperation and successful remediation demonstrated an adequate corrective response.

The facility had multiple severe violations including failure to maintain medication records (16 residents affected), non-functioning ventilation systems in 9 rooms, missing staff training documentation (3 of 6 staff), incomplete TB screening (2 of 6 staff), unsigned service agreements (2 of 3 residents), undocumented safety plans for blood-thinning medications (3 residents), and inadequate infection control measures including failure to maintain respiratory protection program and improper handling of isolation precautions. The facility responded promptly with investigations and corrective actions during the inspection, completing immediate remediation for several deficiencies, updating policies, and implementing systemic improvements. All deficiencies were corrected and verified by follow-up inspection on 08/23/2024, demonstrating sustained compliance.

The facility had two administrative compliance violations: failure to report an administrator change within the required 10-day timeframe and improper TB testing procedures for newly hired staff. These are procedural violations with no direct resident harm indicated. The facility acknowledged the deficiencies during the investigation, and the investigator documented the failed practices through employee file reviews and STARS system checks, though the report does not detail specific corrective actions taken beyond the citation issuance.

The facility failed to read tuberculosis test results for two staff members within the required 48-72 hour timeframe, placing residents at risk of exposure to a communicable respiratory disease. This violation was particularly concerning as it was an uncorrected repeat deficiency previously cited on March 7, 2023, resulting in a $300 civil fine. The facility's response was inadequate, as evidenced by the failure to correct the issue after the initial citation, demonstrating a pattern of non-compliance with critical infection control requirements.