Jeff Davis Living Center, LLC

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) provided services for 8 consecutive hours a day, 7 days a week and ensure the DON (Director of Nursing) did not serve as a charge nurse when the facility had an average daily census over 60 residents. Findings: Review of RN staffing timesheets from 10/01/2024-04/27/2025 revealed the RN did not work 8 consecutive hours the following dates: 11/10/2024 7.75 hours worked 11/23/2024 7.75 hours worked 12/31/2024 7.75 hours worked 01/03/2025 7.32 hours worked 01/28/2025 no RN hours worked 02/05/2025 6.75 hours worked 02/28/2025 7.92 hours worked 03/28/2025 7.88 hours worked 04/15/2025 5.75 hours worked On 04/28/2025 at 10:00 a.m., an interview was conducted with S2DON and S3RN. S2DON stated that on Saturday and Sunday the weekend RN is scheduled to work an 8 hour shift each day. S2DON stated that Monday through Friday, S3RN is scheduled to work an 8 hour shift each day. S2DON and S3RN reported that when S3RN is not present in the facility for her scheduled weekday 8 hour shift, S2DON serves as the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's status, for 1(#24) of 32 sampled residents Findings: A review of Resident #24's medical records revealed an admission date of 07/26/2017 with diagnoses which included but were not limited to Major Depressive Disorder and Bipolar Disorder. A review of Resident #24's Pre admission Screening and Assessment Resident Review (PASRR) revealed a Level II determination that read, The individual has a serious mental illness and is recommended nursing home admission. A review of Resident #24's annual MDS with an ARD (Assessment Reference Date) of 02/06/2025 revealed the following: Section A1500 -Is the resident currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The answer was coded 0 for no. On 04/29/2025 at 1:04 p.m., an interview and review of Resident #24's MDS was conducted with S2DON (Director of Nursing). She confirmed that the PASRR was incorrectly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews and record review, the facility failed to ensure a resident's plan of care was implemented for 1 (#41) out of 1 (#41) residents investigated for positioning out of a total sample of 32 residents. Findings: A review of Resident #41's Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, cerebral infarction, cerebrovascular disease, and hemiplegia and hemiparesis. A review of Resident #41's Care Plan revealed a care plan intervention initiated on 10/11/2022 that read, staff instructed to check on resident's body alignment when passing by room and or after care and turning and repositioning her. Further review of the resident's care plan dated 08/15/2022 read in part .provide pressure reduction/relief mattress on bed. Assist positioning for comfort. Monitor frequently, at least every two hours for pressure redistribution and assist with repositioning as indicated. Review of the air mattress manufactures manual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to implement policies and procedures for Enhanced Barrier Precautions (EBP) for 1 (#11) of 2 (#11, #27) residents sampled for wound care, with a total sample of 32 residents. Findings: Review of the facility's EBP policy revised on 03/2024 revealed the following, in part: EBP are used as in infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. Review of the medical record for Resident #11 revealed an admission date of 12/22/2025 with diagnoses including peripheral vascular disease, and type 2 diabetes mellitus. Review of the March 2025 Physician's orders revealed an order dated 07/15/2024 which read in part enhanced barrier precautions. Further review revealed an order dated 03/26/2025, which read in part .venous stasis ulcer anterior right lateral lower leg: clean with normal saline, apply hydrofer blue dressing then cover. On 04/28/2025 at 10:20 a.m., an observation of wound care was conducted with S2DON (Director of Nursing) and S4TX…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of policy and procedure and interviews, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety by failing to follow appropriate food handling practices as evidenced by: 1. Failing to ensure staff present in the kitchen covered their facial hair. 2. Food storage: A. Refrigerated items: 1. A container of peaches not labeled with the date it had been prepared. 2. A bag of mozzarella cheese and cheddar cheese opened and not labeled with the date it had been opened or placed in a closed bag. 3. A container of ranch dressing with an expiration date of 11/2023. 4. A container of honey mustard with an expiration date of 09/2023. B. Dry Storage 1. One dented canned good in the dry storage room. C. Walk-in freezer: 1. One box of boneless chicken on the floor. 2. One box of hot dog buns on the floor. 3. No thermometer noted on the inside. 4. No record of daily temperatures. The total amount of residents that ate out of the kitchen was 74 residents. Findings: Review of the facility's policy, Food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the residents' assessment accurately reflected the status of 2 (# 53 and # 59) residents out of a total of 30 sampled residents by failing to ensure that: 1. Resident # 53 was coded correctly for anticoagulant use. 2. Resident # 59 was coded correctly for dialysis treatment. Findings 1. Review of Resident # 53's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Anemia, Schizoaffective Disorder, Bipolar Disorder, Cardiac Pacemaker and Aphasia. Review of Resident # 53's Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 11/23/2023 revealed in Section N - High-Risk Drug Classes: Use and Indication Drug Class E. Anticoagulant (e.g., Warfarin, Heparin, or low-molecular weight Heparin) was checked for 1. Is taking. Review of Resident # 53's November 2023 physician's ordered revealed no orders for use of anticoagulants. On 03/11/2024 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure routine medications were disposed of when expired. The deficiency had the potential to affect a census of 77 residents. Findings: Review of the facility's policy on 03/12/2024, titled, Medication Labeling and Storage, with a policy revised date of February 2023, read in part: . 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. On 03/12/2024 at 9:30 a.m., an observation of the facility's Hall A medication storage room was conducted with S9LPN (Licensed Practical Nurse). On 03/12/2024 at 9:58 a.m., an interview was conducted with S9LPN, who confirmed the following expired medications were present/identified in the residents' storage bins Phenergan 25mg (milligrams) suppository (6 suppositories) with an expiration date of 03/2023 Losartan K+ 50mg (30 tablets) with an expiration date of 01/31/2024 Amantadine 100mg (30 tablets) with an expiration date of 08/31/2022 Citalopram 20mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure menus met the nutritional needs of the residents and were followed as evidenced by kitchen staff failing to have knowledge of recipes to be followed when preparing pureed foods. This deficient practice had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs and weight loss for the 3 residents who consumed pureed diets. Findings: On 03/12/2024 at 9:25 a.m., an observation was made of S6DC (Dietary Cook) preparing pureed lunch meals. S6DC prepared an unmeasured amount of ham by blending the pieces of ham into the blender and added an unmeasured amount of water. Next, S6DC was observed transferring an unmeasured amount of green bean casserole from the container to the blender and then added and unmeasured amount of water and blended all the ingredients. There were no recipe(s) present during the observed pureed lunch meal preparation by S6DC. On 03/12/2024 at 9:35 a.m., an interview was conducted with S6DC who confirmed she was one of the cooks at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to implement an antibiotic stewardship program to ensure antibiotic use was being monitored and trending was being performed for residents receiving antibiotics. Findings: Review of the facility's Antibiotic Stewardship Program Policy revealed in part: Tracking: Process measures: Collect, review and report types of antibiotics ordered. Who ordered the antibiotic (attending, on call physician or nurse practitioner), Review and track whether appropriate tests such as cultures were obtained prior to prescribing antibiotics, are cultures (C&S) results communicated as soon as possible and changes in antibiotic therapy during course of treatment. Review of the Antibiotic Stewardship binder on 02/07/2023 revealed the tracking and trending of infections and antibiotic use for the months November 2022, December 2022 and January 2023, were incomplete. The logs revealed the following: 1. November 2022 Infection Control Log revealed 11 reported infections. 3 did not have a date the physician was notified, and 5 did not have a stop date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the provider failed to ensure dinnerware sanitization was achieved when dishwasher temperatures failed to reach the minimally required temperature and chemical used to sanitize dishware during the process failed to be delivered into the system. This deficient practice had the potential to effect 71 residents that consumed meals and/or beverage prepared and served from the facility kitchen. Findings: On 02/05/2023 at 8:35 a.m. a tour of the facility's kitchen was conducted. During this time, S4DA (Dietary Aid) was asked to demonstrate use of the dishwasher, including confirmation of the sterilization process by litmus paper test. S4DA initiated three consecutive wash cycles, all of which failed to reach the minimally required temperature of 120 degrees Fahrenheit. Additionally, S4DA attempted three chemical sterilization tests using litmus paper; all failed to register any color change, indicating sterilization had not been achieved. S4DA examined the small, clear hose used to deliver liquid sterilizing agent into the system and discovered it was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.