Complete Care at Jefferson Meadows LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Jefferson Meadows LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF700Jan 31, 2025

  Based on observation, interview, and record review, the facility failed to ensure other alternatives were tried prior to installing/utilizing side rails. The facility failed to identify and recognize that the use of side rails with an air mattress increases the risk for entrapment for 12 of 12 residents in the facility (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12) who use a side rail and an air mattress. On [DATE], the facility implemented the use of a side rail for R1. The facility failed to ensure other alternatives were tried prior to installing/utilizing side rails/enabler device for R1. […]

• Immediate jeopardy, isolatedF686Feb 27, 2023

  Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident did not develop a pressure injury (PI) and that the resident received necessary treatment and services to promote healing and prevent infection of the pressure injury for 2 of 4 residents sampled for pressure injuries (R2 and R9). R2 had a history of pressure injuries and was at risk for PI development. The facility failed to implement aggressive measures upon admission, failed to update R2's MD timely when a new pressure injury developed, failed to re-evaluate interventions that were not working, failed to update the care plan timely, failed to complete diabetic foot checks per current standards of practice, and failed to use R2's offloading boots… […]

• Actual harm, isolatedF692May 13, 2025

  Based on observation, interview and record review, the facility failed to ensure residents received adequate nutrition and fluid intake for 3 (R25, R26, R42) of 4 Residents reviewed for nutrition. R25 is being cited at severity level 3 (actual harm). R26 and R42 are being cited at severity level 2 (potential for more than minimal harm). R25 was admitted to the hospital on 12/16/24 for weakness, anorexia, and severe hypernatremia (a high concentration of sodium in the blood often caused by dehydration). R25's sodium was 169. […]

• No harm, potential for more than minimal, widespreadF851Jul 21, 2026

  Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS). This has the potential to affect all 43 residents that reside in the facility.The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for three fiscal year quarters for excessively low weekend staffing and for one fiscal year quarter for one star staffing rating, and no Registered Nurse (RN) hours.Evidenced by:The facility's Payroll Based Journal policy, dated as revised 2/2026, states, in part: Policy: It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information,… […]

• No harm, potential for more than minimal, widespreadF812May 13, 2025

  Based on observation, interview, and record review, the facility did not ensure food was prepared and served in a safe and sanitary manner. This practice has the potential to affect all 48 residents who reside at the facility. Surveyor observed dietary staff directly touching food with bare hands. Surveyor observed staff enter kitchen area while food service was taking place, not wearing a hair restraint. Evidenced by: The facility policy, Food Safety Requirements, dated 2/25, states, in part; .7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. a. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas .d. […]