Complete Care At Jefferson Meadows LLC

Penalties

• May 13, 2025 — Fine ($19,135)
• Jan 31, 2025 — Fine ($35,191)

Inspection findings

1. Jul 2, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jul 15, 2026 · CMS health inspection

2. May 13, 2025 Health · 25 findings
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Jun 10, 2025 · CMS health inspection

   • Serious Scope/severity G

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0740 Quality of Life and Care Deficiencies

     Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0849 Administration Deficiencies

     Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity C

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Jun 10, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected Jun 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Jun 10, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jun 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jun 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jun 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jun 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jun 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jun 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0754 Miscellaneous Deficiencies

     Provide properly sized and located linen or trash receptacles.

     Corrected Jun 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jun 10, 2025 · CMS fire safety

3. Jan 31, 2025 Health · 1 finding
   • Serious Scope/severity K Complaint

     F0700 Quality of Life and Care Deficiencies

     Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

     Corrected Feb 21, 2025 · CMS health inspection

4. May 14, 2024 Fire Safety · 6 findings
   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jun 7, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected May 24, 2024 · CMS fire safety

5. Feb 27, 2023 Health · 14 findings
   • Not serious Scope/severity D

     F0561 Resident Rights Deficiencies

     Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

     Corrected Mar 24, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Mar 24, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Mar 13, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0604 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

     Corrected Mar 13, 2023 · CMS health inspection

   • Serious Scope/severity J

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 24, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Mar 24, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Mar 24, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Feb 18, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Mar 7, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Mar 6, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Mar 2, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 3, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Feb 28, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Feb 18, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• FLYGT, THOMAS — adp of the snf, NOT APPLICABLE, since 02/28/2025
• FLYGT, THOMAS — operational/managerial control, NOT APPLICABLE, since 02/28/2025
• GREENWOOD, EMILY — adp of the snf, NOT APPLICABLE, since 02/28/2025
• GREENWOOD, EMILY — operational/managerial control, NOT APPLICABLE, since 02/28/2025
• HELLMAN, YOSEF — operational/managerial control, NOT APPLICABLE, since 02/28/2025
• HELLMAN, YOSEF — managing control - governing body, NOT APPLICABLE, since 02/28/2025
• KLUGMAN, JACOB — indirect ownership interest, NOT APPLICABLE, since 02/28/2025
• KLUGMAN, JACOB — adp of the snf, NOT APPLICABLE, since 02/28/2025
• LEVERENTZ, LUANNE — adp of the snf, NOT APPLICABLE, since 02/28/2025
• PENDLETON, JULIE — operational/managerial control, NOT APPLICABLE, since 02/28/2025
• PENDLETON, JULIE — adp of the snf, NOT APPLICABLE, since 02/28/2025
• STEIN, SHALOM — managing control - governing body, NOT APPLICABLE, since 02/28/2025
• STEIN, SHALOM — trustee of the snf, NOT APPLICABLE, since 02/28/2025
• STEIN, SHALOM — indirect ownership interest, NOT APPLICABLE, since 02/28/2025
• STEIN, SHALOM — corporate officer, NOT APPLICABLE, since 02/28/2025
• STEIN, SHALOM — adp of the snf, NOT APPLICABLE, since 02/28/2025
• STERNBUCH, DANIEL — operational/managerial control, NOT APPLICABLE, since 02/28/2025
• STERNBUCH, DANIEL — adp of the snf, NOT APPLICABLE, since 02/28/2025
• DES CAPITAL LLC — adp of the snf, NOT APPLICABLE, since 02/28/2025
• JRK INVESTMENTS LLC — adp of the snf, NOT APPLICABLE, since 02/28/2025
• PC WCM OPCO HOLDCO LLC — 5% or greater direct ownership interest, 100%, since 02/28/2025
• PC WCM PROPCO HOLDCO LLC — adp of the snf, NOT APPLICABLE, since 02/28/2025
• PC WCM TOPCO LLC — adp of the snf, NOT APPLICABLE, since 02/28/2025
• PC WCM TOPCO LLC — 5% or greater indirect ownership interest, since 02/28/2025
• PEACE CAPITAL HOLDINGS II LLC — adp of the snf, NOT APPLICABLE, since 02/28/2025
• PEACE CAPITAL HOLDINGS II LLC — 5% or greater indirect ownership interest, since 02/28/2025
• SMS 2021 TRUST — 5% or greater indirect ownership interest, since 02/28/2025
• SMS 2021 TRUST — adp of the snf, NOT APPLICABLE, since 02/28/2025
• ST. CLARE PROPCO LLC — adp of the snf, NOT APPLICABLE, since 02/28/2025