Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Jefferson during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dysphagia, and multiple comorbidities had a care plan and MD orders requiring monitoring and intervention for poor intake, including use of health shakes when less than half of a meal was consumed. Over an extended period, documentation showed repeated meal refusals and 0–25% intake, yet there was no record that health shakes were provided or that the MD or resident representative were notified. On one occasion, the resident became combative, refused medications, would not allow vital signs to be taken, and would not swallow, but this was not documented as having been reported to the nurse or MD. The MD and resident representatives reported they were not informed of the poor intake or refusals, while facility staff and leadership acknowledged that such changes should have been reported per the facility’s change-in-condition policy, resulting in a deficiency for failure to promptly notify the physician and representative of significant changes in condition.
Surveyors found that the facility did not complete or update comprehensive care plans for two residents and failed to implement a prescribed nutrition order. One resident with multiple CVA-related deficits, pain, incontinence, fall and pressure-ulcer risk, and several high-risk medications had a care plan that only addressed skin integrity and a prior fall, omitting allergies, code status, cognition, incontinence, ADLs, pain, diet, disease processes, and medication-related risks. Another resident with severe cognitive impairment and extensive neuro and medical conditions had an ADL care plan that still stated he could feed himself, despite MDS documentation that he was totally dependent for eating, and staff did not document providing ordered health shakes when he consumed less than 50% of meals, even though intake records repeatedly showed poor or refused intake.
The facility failed to maintain kitchen sanitation and food safety standards, with the Dietary Manager not wearing proper facial coverings and the kitchen having cleanliness issues like food particles on the dishwasher and grease buildup on the stove. Despite policies requiring a cleaning schedule and hair restraints, these were not followed or documented, posing a risk of food contamination.
The facility failed to provide adequate respiratory care for three residents, leading to potential risks of respiratory infections. A resident's oxygen tubing was not changed as ordered, another resident's humidification bottle was found dry, and tracheostomy care for a third resident was not performed using aseptic techniques. These deficiencies were confirmed through observations and staff interviews.
The facility failed to ensure call buttons were within reach for three residents, compromising their ability to request assistance. A resident with pneumonia, dementia, and hypertension had her call button on the floor, out of reach. Another resident with heart conditions had her call button far under her bed, and a third resident with muscular degeneration had her call button behind a dresser. Staff interviews confirmed the responsibility to ensure call buttons are accessible, as per facility policy.
The facility failed to complete and provide baseline care plans within 48 hours of admission for three residents, including an 85-year-old male with multiple health issues, a male with sepsis and heart disease, and a male with heart disease and COPD. The care plans were either outdated, undated, or lacked necessary signatures, and responsible parties were not provided with copies. Staff interviews revealed confusion about responsibilities, contributing to these deficiencies.
The facility failed to update care plans for two residents, one with a reopened Stage IV pressure ulcer and another with a history of falls. The MDS Coordinator and nursing staff did not ensure care plans reflected current conditions, leading to deficiencies in addressing medical and safety needs. Interviews revealed a lack of communication and responsibility among staff, contributing to the oversight.
Two residents at high risk for pressure ulcers were found to have incorrect settings on their pressure-relieving mattresses, with one set at 350 pounds and the other at 50 pounds, despite their actual weights being 203 and 230 pounds. Nursing staff, including RNs and LVNs, were unclear about who was responsible for monitoring these settings, leading to a failure in adhering to the facility's policy on pressure injury prevention. This oversight placed the residents at risk for developing or worsening pressure ulcers.
A resident with an indwelling catheter and a history of urinary tract infections exhibited symptoms such as red-tinged urine and increased confusion. Despite these signs, the nursing staff failed to document or report the red-tinged urine to the physician, delaying necessary medical intervention. This oversight led to the resident being sent to the emergency room with symptoms of septic shock.
A resident with moderately impaired cognition was left with a dose of Gabapentin at their bedside, contrary to the facility's policy that requires medications to be administered safely and timely. Interviews with staff confirmed that medications should not be left unattended, as it poses a risk of drug diversion and incorrect dosages.
A resident with dementia was administered Quetiapine, an antipsychotic, without an appropriate diagnosis or indication of use. Facility staff expressed confusion over the proper use of antipsychotics, with some stating that dementia is not a suitable diagnosis for such medication. The facility's medication reconciliation process failed to ensure a justified use of Quetiapine, despite pharmacy recommendations for alternative therapy.
A resident in the facility experienced significant medication errors due to improper scheduling of Levothyroxine and Pantoprazole. Despite the need for specific timing to ensure therapeutic effects, these medications were administered at suboptimal times, as confirmed by staff interviews and record reviews. The facility lacked a process to review medication administration times, leading to ineffective treatment and potential adverse reactions.
A facility failed to report a drug diversion incident involving a resident's hydromorphone medication to the State Survey Agency. The medication was tampered with, and the ADM did not report it, believing the hospice company would handle it. The resident, who had Parkinson's, COPD, and diabetes, was not harmed as he had additional medication available. The facility's policy required reporting such incidents within 24 hours, which was not followed.
A resident with Alzheimer's and osteoporosis was improperly handled by staff, who failed to follow facility policy for safe repositioning. Video evidence showed staff pulling the resident by the wrist and arms, contrary to the policy requiring two staff members and a draw sheet. Staff cited the resident's combative behavior and personal limitations as reasons for not following proper procedures.
A resident with a history of diabetes and muscle wasting experienced pain during wound care treatment, but the facility failed to provide appropriate pain management. Despite the resident's complaints and visible signs of pain, the treatment nurse did not offer pain medication or hold the procedure, and the resident's physician orders did not include PRN pain medications.
The facility failed to maintain an infection prevention program, leading to potential infection risks for four residents. The Treatment Nurse did not wash her hands or change gloves appropriately during wound care procedures, as observed and confirmed through interviews and record reviews. The DON and ADON acknowledged the nurse's incomplete training and misunderstanding of hand hygiene protocols.
Failure to Notify Physician and Representative of Resident’s Poor Intake and Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and resident representative (RP) of significant changes in the resident’s condition, including poor oral intake, refusal of meals, and refusal of medications, as required by facility policy. The resident was an older adult with multiple serious diagnoses, including cerebral infarction, dysphagia, cerebrovascular disease, chronic kidney disease, right eye blindness, vascular dementia, malignant brain neoplasm, repeated falls, depression, and hypertension. A quarterly MDS showed severe cognitive impairment (BIMS score of 7), total dependence for all ADLs including eating, wheelchair use, and complete bowel and bladder incontinence. The care plan identified a nutritional problem or risk and directed staff to monitor, document, and report to the MD as needed for signs and symptoms of dysphagia, including refusing to eat. Record review showed an order for a health shake to be given if the resident consumed less than 50% of a meal, with instructions to encourage intake and notify the nurse. The MAR and order summary contained this order, but there was no documentation that the resident ever received a health shake during the review period. Nutrition intake records documented repeated days where the resident ate 0–25% of meals, refused entire meals, or had missing documentation for some meals over multiple days. Despite this pattern of poor intake and refusals, nurses’ notes from the beginning to the middle of the month did not show that the physician or the resident’s RP were notified about the resident’s refusal of meals or poor eating. On one date, a medication aide documented that the resident was resistant to medication administration, swinging and swatting, not allowing blood pressure to be taken, and not swallowing anything, but there was no documentation that the nurse was notified of this behavior. In interviews, the resident’s RPs stated they had not been informed of the resident’s refusal to eat or take anything by mouth and indicated they would have intervened had they known. The physician reported he did not recall being notified that the resident was not eating well or that the resident was combative and refusing medications, and stated he would have expected notification so he could implement interventions. Facility staff, including an LVN, the DON, and the ADM, acknowledged in interviews that such changes in condition, including meal refusals, medication refusals, and abnormal behaviors, should have been reported to the nurse, the physician, and the RP, in accordance with the facility’s written policy on change in condition, which requires prompt notification of the physician and representative for significant changes and for refusal of treatment or medications three or more consecutive times. The facility’s policy titled "Change in a Resident's Condition or Status" required the nurse to notify the attending or on-call physician when there was a significant change in the resident’s physical, emotional, or mental condition, and when there was refusal of treatment or medications three or more consecutive times. It also required notification of the resident’s representative when there was a significant change in the resident’s physical, mental, or psychosocial status, with notifications to be made within 24 hours of the change, except in emergencies. Despite these requirements, the record and interview evidence showed that the physician and RPs were not notified of the resident’s ongoing poor oral intake, repeated meal refusals, and the episode of combative behavior and medication refusal, leading to the cited deficiency for failure to promptly notify the physician and resident representative of changes in condition.
Failure to Develop and Implement Comprehensive Care Plans and Nutrition Orders for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans addressing all identified needs for two residents, as required by facility policy and the MDS assessments. For one resident with cerebrovascular disease, hemiplegia/hemiparesis following cerebral infarction, adult failure to thrive, polyneuropathy, hypertension, atherosclerotic heart disease, and nutritional deficiency, the admission MDS showed moderate cognitive impairment (BIMS 12), functional limitations in range of motion, wheelchair use, partial to substantial assistance with most ADLs, frequent urinary incontinence and occasional bowel incontinence, frequent pain requiring scheduled pain medication, a history of falls, risk for pressure ulcers, and use of antidepressant, diuretic, opioid, antiplatelet, and anticonvulsant medications. Despite this, the resident’s care plan, with an admission date of 1/18/26, contained only two problem areas: risk for impaired skin integrity/wound and an actual fall, and did not include problem areas or interventions for allergies, discharge plans, code status, cognitive status, incontinence status, activities, pain management, diet, ADL assistance, fall risk, pressure ulcer risk, bleeding risk, preferences, disease processes, or the listed medications. Observation and interview with this resident showed he was sitting in a wheelchair and reported he could not use his right arm or leg and had previously been very independent and active before his stroke. He stated he was continent of urine but needed assistance to use a urinal because he could not manage his clothing and hold the urinal with one hand, and he expressed reluctance to ask for help while also not wanting to soil himself. He also stated he was angry about his current health situation, that his whole life had changed, and that he did not feel the facility realized that. The MDS Coordinator acknowledged that the comprehensive care plan was her responsibility along with another MDS Coordinator, that it should include areas such as code status, diet, allergies, assistance needed, skin, bowel and bladder, medications, fall and pressure ulcer risk, and health conditions, and that the comprehensive care plan for this resident was not completed within the required 21 days from admission. For the second resident, who had diagnoses including cerebral infarction, dysphagia, cerebrovascular disease, chronic kidney disease, right eye blindness, vascular dementia, malignant neoplasm of the brain, cognitive symptoms following cerebral infarction, repeated falls, depression, and hypertension, the quarterly MDS indicated severe cognitive impairment (BIMS 7), wheelchair use, dependence on staff for all ADLs including eating, and continuous bowel and bladder incontinence. However, the resident’s ADL care plan, with an admission date of 12/27/25, still described an ADL self-care performance deficit related to confusion and impaired balance and stated that the resident was able to feed himself with meal and tray set-up, last revised on 8/20/25, and was not updated to reflect dependence on staff for eating. Additionally, there was a physician order, present on the order summary and MAR, for the resident to receive a health shake if less than 50% of a meal was consumed, with encouragement of intake and notification of the nurse, but there was no documentation that the resident ever received a health shake during the review period, despite multiple documented meals where intake was 0–25%, 26–50%, or refused. Nursing notes did not indicate that health shakes were offered or refused. Facility staff, including LVNs, the MDS Coordinator, the DON, the physician, and the administrator, stated that the comprehensive care plan is intended to direct resident care, should be complete and accurate, and that physician orders, including the health shake order, should have been followed.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. The Dietary Manager was repeatedly seen without proper facial hair covering, which is a requirement for maintaining hygiene in food preparation areas. Despite acknowledging the need for facial coverings, the Dietary Manager reported that the provided coverings did not fit properly and had informed the previous manager and the ADM about this issue. However, no corrective action was taken to address the ill-fitting facial coverings. Interviews with dietary staff confirmed that all kitchen staff, including those with facial hair, were expected to wear appropriate hair restraints to prevent contamination of food. Additionally, the facility's kitchen was found to have cleanliness issues, including food particles on top of the dishwasher and grease buildup on the gas stove. The Dietary Aide responsible for cleaning the dishwasher admitted to not having a checklist to mark completed tasks, leading to uncertainty about when the dishwasher was last cleaned. The Dietary Manager also acknowledged the presence of food particles and grease buildup, stating that there was no documentation or checklist for cleaning these areas. The lack of a structured cleaning schedule and verification process contributed to these sanitation lapses. The facility's policies, dated October 2018, outlined the need for a cleaning schedule and employee sanitation practices, including the use of hair restraints. However, the cleaning schedule was not being followed or documented as required. The ADM and DON both expressed expectations for a cleaning checklist to be in place and initialed upon task completion, but this was not being enforced. The absence of proper documentation and oversight in the kitchen cleaning process posed a risk of food contamination, potentially leading to foodborne illnesses among residents.
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to potential risks of respiratory infections. For Resident #8, the facility did not change the oxygen tubing as per the physician's order, which required weekly changes every Friday. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that it was the responsibility of the nursing staff to ensure the oxygen tubing was changed and labeled with the new date, as failure to do so could place residents at risk for respiratory infections. Resident #48's care was compromised as the humidification bottle attached to her nasal cannula was found to be without water. The resident, who was on oxygen therapy due to congestive heart failure and ineffective gas exchange, was observed with a dry humidification bottle, which could lead to a dry nose and potential nosebleeds. The resident was unable to recall how long the bottle had been dry, and the nursing staff failed to ensure the bottle was filled, as confirmed by interviews with LVN Q and LVN R. For Resident #190, the facility did not adhere to aseptic techniques during tracheostomy care. LVN Q performed the procedure without using the prescribed sterile water and prepared solution, instead using normal saline. The trach care kit was contaminated when LVN Q used non-sterile gloves to handle items, and the tracheostomy cannula was not removed and cleaned as required. Additionally, the trach tube holder was changed without the assistance of a second staff member, contrary to the facility's policy. These actions placed the resident at risk for infection, as acknowledged by LVN Q and the DON during interviews.
Failure to Ensure Call Buttons Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call buttons for three residents were within reach while they were in bed, which is a violation of their right to reasonable accommodation of needs and preferences. Resident #7, a female with pneumonia, dementia, and hypertension, was found with her call button on the floor, out of reach, while her bed was in a high position. She reported that the call button had been on the floor all night and morning, leaving her unable to request assistance. Resident #17, a female with systolic heart failure, hypertensive heart disease, and a history of myocardial infarction, also had her call button out of reach, far under her bed. She expressed that she never used her call button because she could not reach it and needed someone to hand it to her. Her care plan indicated that staff should anticipate and meet her needs, ensuring the call light was within reach. Resident #50, a female with muscular degeneration, hyperlipidemia, and hypertension, had her call button several feet away behind a dresser, making it inaccessible. Interviews with staff, including a CNA, the DON, and the ADM, confirmed that it was the responsibility of all staff to ensure call buttons were within reach. The facility's policy on answering call lights emphasized the importance of making call lights accessible to residents.
Failure to Complete and Distribute Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed and provided to residents and/or their representatives within 48 hours of admission for three residents. Resident #36, an 85-year-old male with multiple diagnoses including a fracture, vascular dementia, and diabetes, did not have a baseline care plan completed for his admission on 09/04/24. The facility provided a care plan dated from a previous admission, indicating a failure to update and complete a new plan for the current admission. Resident #2, a male with a history of sepsis, megaloureter, and atherosclerotic heart disease, had an undated baseline care plan that lacked signatures from the resident, representative, and staff. This indicates that the care plan was not properly completed or communicated to the responsible party. Attempts to contact the responsible party were unsuccessful, and no documentation was provided to show that the care plan was shared with them. Resident #190, a male with conditions such as atherosclerotic heart disease and COPD, also had an undated baseline care plan without necessary signatures. The responsible party for Resident #190 reported not receiving a copy of the care plan, which would have been helpful in understanding the resident's care needs. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion and distribution of baseline care plans, contributing to the deficiencies observed.
Deficiencies in Care Plan Implementation for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their medical and safety needs. For one resident, the care plan did not address a Stage IV sacral pressure ulcer that had reopened. Despite the ulcer being noted in the resident's medical records, the MDS Coordinator did not update the care plan to reflect the current condition, which was acknowledged as an oversight. Interviews with the MDS Coordinator, DON, and ADM confirmed that the responsibility for updating care plans was shared among nursing management, but the necessary updates were not made. Another resident's care plan failed to incorporate new interventions and updates for fall prevention, despite a history of multiple falls. The resident had been readmitted with several diagnoses, including protein-calorie malnutrition, dysphagia, COPD, Parkinson's disease, and epilepsy. The care plan had not been updated to reflect recent falls or to implement effective interventions. Interviews with various staff members, including CNAs, LVNs, and the DON, revealed a lack of awareness and communication regarding the resident's fall risk and the necessary interventions. The facility's policy on fall risk management was not effectively implemented, as evidenced by the absence of updated care plans and fall risk assessments. The facility's failure to update and implement care plans for these residents highlights a breakdown in communication and responsibility among the staff. The MDS nurse, DON, and other nursing staff were responsible for ensuring that care plans were current and reflective of each resident's needs. However, the lack of updated care plans and the failure to conduct timely fall risk assessments contributed to the deficiencies identified by the surveyors. The facility's policies on comprehensive care planning and fall risk management were not adequately followed, leading to potential risks for the residents involved.
Failure to Ensure Correct Pressure-Relieving Mattress Settings
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #36 and Resident #187, received appropriate care to prevent pressure ulcers. Both residents were at high risk for pressure ulcers, as indicated by their Braden scale scores and medical conditions. Resident #36 had a history of vascular dementia, Type 2 diabetes, and multiple wounds, while Resident #187 had a history of myocardial infarction and Type 2 diabetes. Despite these risks, the pressure-relieving mattresses for both residents were set incorrectly, with Resident #36's mattress set at 350 pounds and Resident #187's at 50 pounds, which did not correspond to their actual weights of 203 pounds and 230 pounds, respectively. Observations and interviews revealed a lack of clarity and responsibility among the nursing staff regarding the monitoring and adjustment of the pressure-relieving mattress settings. RN G, RN S, LVN Q, and LVN R all expressed uncertainty about who was responsible for ensuring the correct settings. RN S, the wound care nurse, acknowledged the importance of correct settings to prevent pressure ulcers and admitted that the settings for both residents were incorrect. The Director of Nursing (DON) and the Administrator (ADM) also confirmed that the nursing staff was responsible for checking and adjusting the mattress settings. The facility's failure to maintain the correct settings on pressure-relieving mattresses placed the residents at risk for developing or worsening pressure ulcers. The facility's policy on the prevention of pressure injuries emphasized the importance of selecting appropriate support surfaces based on residents' risk factors, but this was not adhered to in practice. The incorrect settings could lead to unnecessary pressure ulcers, skin breakdown, and discomfort for the residents.
Failure to Report Changes in Resident's Condition Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in preventing urinary tract infections. The resident, who had a history of urinary tract infections and other medical conditions, exhibited symptoms such as red-tinged urine, increased confusion, and an elevated white blood cell count. Despite these symptoms, the nursing staff did not document or report the red-tinged urine to the physician, which was a critical oversight given the resident's medical history and current symptoms. The report highlights that LVN Q observed the resident's pink-tinged urine but failed to document it or notify the physician, MD T, about this significant change. Although LVN Q communicated the elevated white blood cell count to the physician, the omission of the red-tinged urine was a crucial lapse. This lack of communication and documentation was compounded by the fact that the resident had been previously noted to have increased confusion, a symptom that could indicate a urinary tract infection. Further interviews revealed that the nursing staff, including LVN M and the DON, acknowledged the importance of notifying the physician about changes in the resident's condition. However, the failure to report the pink-tinged urine delayed the necessary medical intervention, ultimately leading to the resident being sent to the emergency room with symptoms of septic shock. The facility's policies on catheter care and acute condition changes were not adhered to, contributing to the deficiency in care provided to the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident. Specifically, staff left a dose of Gabapentin at the bedside of a resident who was not care planned to self-administer medications. The resident, who had a moderately impaired cognition as indicated by a BIMS score of 12, was unaware of the missed dose until informed by the surveyor. This oversight was observed during a survey, highlighting a lapse in the medication administration process. Interviews with facility staff, including a Certified Medication Aide (CMA), the Director of Nursing (DON), and the Administrator (ADM), confirmed that the medication aide is responsible for ensuring residents take or refuse their medications before leaving the room. The facility's policy on administering medications, dated April 2019, requires that medications be administered safely and timely, and any refused medication should be discarded. The failure to adhere to these procedures could lead to residents taking medications not prescribed to them, posing a risk of drug diversion and incorrect therapeutic dosages.
Inappropriate Use of Antipsychotic Medication for Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident, who had not previously used psychotropic drugs, was not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified for one resident who was administered Quetiapine, an antipsychotic medication, without an appropriate diagnosis or indication of use. The resident, an elderly female with a history of dementia, heart failure, atrial fibrillation, hypothyroidism, atherosclerotic heart disease, anxiety, and depressive episodes, was taking Quetiapine for unspecified dementia with psychotic disturbances, which was not adequately justified in her clinical records. Interviews with facility staff revealed inconsistencies and misunderstandings regarding the appropriate use of antipsychotic medications. LVN F stated that a resident with dementia should not be prescribed antipsychotic medication and emphasized the importance of clarifying diagnoses before administration. RN G and MDS Nurse H also expressed concerns about the appropriateness of using antipsychotics for dementia, indicating that diagnoses such as schizophrenia or bipolar disorder would be more suitable. The ADON and DON provided conflicting views, with the DON asserting that the medication was appropriate for unspecified dementia with psychotic disturbances, while the ADON acknowledged the need for proper diagnosis verification. The facility's medication reconciliation process was found to be lacking, as evidenced by the absence of a clear diagnosis supporting the use of Quetiapine for the resident. The pharmacy consultation had previously recommended considering alternative therapy due to the lack of an approved indication for the medication. Despite these recommendations, the facility did not provide a copy of their policy for psychotropic medication use, and there was no documentation of a comprehensive review or resolution of the medication discrepancy.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Levothyroxine and Pantoprazole. The resident, an 85-year-old male with diagnoses of hypothyroidism and gastro-esophageal reflux disease, was admitted to the facility with a medication regimen that required specific timing for optimal therapeutic effect. However, the medications were not scheduled appropriately, with Levothyroxine being administered at 8 a.m. and Pantoprazole at 9 a.m., contrary to the recommended times for these medications. Interviews with various staff members, including registered nurses and medication aides, revealed a lack of adherence to proper medication administration protocols. The staff acknowledged that thyroid medications like Levothyroxine should be given on an empty stomach and not with other medications, ideally before breakfast. Similarly, Pantoprazole should be administered at least 30 minutes before meals to be effective. The staff admitted that the medications were not scheduled at optimal times, which could render them ineffective and potentially lead to adverse reactions. The Director of Nursing confirmed that the medications were not scheduled therapeutically and that there was no process in place to review medication administration times. The facility's policy on administering medications emphasized the importance of timing for optimal therapeutic effect and preventing interactions, but this was not followed in practice. The deficiency was identified through a combination of record reviews and staff interviews, highlighting a systemic issue in medication scheduling and administration within the facility.
Failure to Report Drug Diversion Incident
Penalty
Summary
The facility failed to report an alleged drug diversion involving a resident's medication to the State Survey Agency and other officials as required by state law. The incident involved a bottle of hydromorphone that was tampered with, which was reported by a Licensed Vocational Nurse (LVN) to the Administrator (ADM) after receiving it from a hospice nurse. The ADM was informed of the tampering but did not report it as a drug diversion, believing it was the responsibility of the hospice company to do so. This oversight was identified during a complaint investigation by a Health and Human Services (HHS) nurse, who advised the ADM to report the incident. The resident involved was an elderly male with Parkinson's disease, COPD, and diabetes mellitus, who had cognitive impairment and required assistance with activities of daily living. Despite the tampering, the resident was not harmed as he had additional sealed bottles of hydromorphone available. The ADM acknowledged the failure to report the incident, stating he did not consider it a drug diversion since it was not his staff involved. The facility's policy required reporting all allegations of drug theft within 24 hours, which was not adhered to in this case.
Improper Resident Handling and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent avoidable accidents for a resident. The resident, who had Alzheimer's Disease, dementia, and osteoporosis, required assistance with activities of daily living (ADLs) and was sometimes understood and sometimes understood others. The resident's care plan noted a behavior problem where she would call out that she was being hurt when no one was touching her. Video evidence revealed improper handling of the resident by staff members. In one instance, a staff member pulled the resident by the wrist into a sitting position, causing the resident to express pain. In another instance, a staff member pulled the resident up in bed by her upper arms. Interviews with staff members indicated that the proper procedure was not followed, as the resident should have been repositioned using a draw sheet or pad with the assistance of two staff members. The facility's policy on repositioning, revised in May 2013, emphasized the use of two people and a draw sheet to avoid shearing while moving a resident. Despite this policy, staff members admitted to not following the correct procedures, citing reasons such as the resident's combative behavior and personal physical limitations. The Director of Nursing and the Administrator both acknowledged that the improper handling could lead to injuries, such as skin tears or fractures.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services. The resident, who was cognitively intact and had a history of diabetes, muscle wasting, and difficulty walking, complained of pain in her heel prior to and during wound care treatment. Despite her complaints and visible signs of pain, such as saying 'ouch' and grimacing, the treatment nurse did not offer any pain medication or hold the wound care procedure. The resident's physician orders did not include any PRN pain medications, and the treatment nurse did not take steps to address the resident's pain during the procedure. The resident's pain assessment indicated mild pain in the last five days, but there was no detailed documentation of the frequency or impact on activities. During an interview, the treatment nurse acknowledged hearing the resident's complaints of pain but did not think to ask if she wanted pain medication. The Director of Nursing (DON) was unaware of the resident's pain until the day of the observation. The facility's Pain Assessment and Management Policy emphasizes the importance of assessing and managing pain, but this was not followed in the case of this resident, leading to her experiencing pain during wound care.
Infection Control Deficiency Due to Improper Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment, leading to potential infection risks for four out of five residents reviewed. The Treatment Nurse did not wash her hands while providing wound treatments for Residents #1, #3, #4, and #5. Additionally, the nurse did not change her gloves between dirty and clean wounds for Resident #1 and did not change gloves from one wound to the next during Resident #5's wound treatments. These actions were observed during wound care procedures and were confirmed through interviews and record reviews. Resident #1, a [AGE]-year-old female with diagnoses including diabetes and muscle wasting, had a wound on her right heel. The Treatment Nurse did not wash her hands before or after the treatment and failed to change gloves after removing a soiled bandage. Resident #3, a [AGE]-year-old with Parkinson's disease and anxiety, received skin prep on her heels without the nurse washing her hands before or after the procedure. Resident #4, a [AGE]-year-old with heart failure and a pressure injury, had her wound treated without the nurse washing her hands, although gloves were changed appropriately. Resident #5, a [AGE]-year-old with dementia, had multiple wounds treated without the nurse changing gloves between different wound sites. During an interview, the DON and ADON acknowledged that the Treatment Nurse was new and had not completed her full training. They also mentioned that the nurse was in school to receive her RN license and would be sent to wound care classes upon completion. The ADON incorrectly stated that hand sanitizer was as effective as soap and water, contrary to the facility's policy. The facility's Wound Care Policy, dated October 2010, requires washing and drying hands thoroughly at multiple stages of the wound care process, which was not followed in these instances.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 32 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jefferson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marshall Manor Nursing & Rehabilitation Center | 16.4 mi | — | 0 | 0 |
| Marshall Manor West | 16.4 mi | — | 18 | 1 |
| Focused Care At Linden | 16.5 mi | — | 10 | 1 |
| Heritage House Of Marshall Health & Rehabilitation | 18.8 mi | — | 3 | 0 |
| Vivian Healthcare Center | 22.6 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Jefferson.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.