Jefferson Nursing And Rehabilitation Center

Penalties

• May 17, 2025 — Fine ($194,652)

Inspection findings

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

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jul 2, 2026 · CMS health inspection

2. Jul 31, 2025 Health · 6 findings
   • Not serious Scope/severity E

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Aug 1, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Aug 1, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Aug 1, 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 Aug 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 4, 2025 · CMS fire safety

3. May 17, 2025 Health · 4 findings
   • Serious Scope/severity K 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 12, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Mar 17, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jun 12, 2025 · CMS health inspection

   • Serious Scope/severity K 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 Jun 12, 2025 · CMS health inspection

4. May 30, 2024 Health · 5 findings
   • Not serious Scope/severity B

     F0640 Resident Assessment and Care Planning Deficiencies

     Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

     Corrected Jun 3, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Jun 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jun 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0926 Environmental Deficiencies

     Have policies on smoking.

     Corrected Jun 3, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 26, 2024 · CMS fire safety

5. Jan 22, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     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 Jan 24, 2024 · CMS health inspection

6. Dec 29, 2023 Health · 2 findings
   • Not serious Scope/severity D Complaint

     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 Jan 3, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     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 Jan 3, 2024 · CMS health inspection

7. Apr 12, 2023 Health · 5 findings
   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Apr 18, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Apr 18, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Apr 18, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0791 Quality of Life and Care Deficiencies

     Provide or obtain dental services for each resident.

     Corrected Apr 18, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected May 12, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ANWAR, SYED — adp of the snf, NOT APPLICABLE, since 01/01/2025
• BAIRD, DANIEL — managing control - governing body, NOT APPLICABLE, since 04/13/2021
• CARVAJAL, ANTONIO — managing control - governing body, NOT APPLICABLE, since 05/16/2024
• CLAPP, BARBARA — managing control - governing body, NOT APPLICABLE, since 06/01/2021
• CORTESE, DAREN — managing control - governing body, NOT APPLICABLE, since 08/10/2021
• DEKOWSKI, DONOVAN — adp of the snf, NOT APPLICABLE, since 01/01/2015
• DEKOWSKI, DONOVAN — operational/managerial control, NOT APPLICABLE, since 01/01/2015
• DOXEY, CYNTHIA — operational/managerial control, NOT APPLICABLE, since 01/01/2026
• DOXEY, CYNTHIA — adp of the snf, NOT APPLICABLE, since 01/01/2026
• FONTENOT, AMY — adp of the snf, NOT APPLICABLE, since 12/18/2023
• FONTENOT, AMY — operational/managerial control, NOT APPLICABLE, since 12/18/2023
• FREGIA, MILTON — managing control - governing body, NOT APPLICABLE, since 05/07/2022
• GARDNER, SHANNON — managing control - governing body, NOT APPLICABLE, since 08/22/2022
• GARDZINA, MARGARET — managing control - governing body, NOT APPLICABLE, since 02/26/2024
• GIBSON, PATRICIA — managing control - governing body, NOT APPLICABLE, since 08/01/2021
• GONZALES, VERONICA — managing control - governing body, NOT APPLICABLE, since 05/16/2024
• HENRY, PAUL — managing control - governing body, NOT APPLICABLE, since 11/30/2014
• KAUFMAN, NICOLE — managing control - governing body, NOT APPLICABLE, since 08/10/2021
• MANDELBAUM, ELLIOT — managing control - governing body, NOT APPLICABLE, since 09/01/2022
• STRATTON, CHARLES — corporate officer, NOT APPLICABLE, since 11/30/2014
• STRATTON, CHARLES — managing control - governing body, NOT APPLICABLE, since 11/30/2014
• 3840 POINT PARKWAY LLC — adp of the snf, NOT APPLICABLE, since 01/01/2015
• CSV RHEA MANAGEMENT HOLDCO, LLC — indirect ownership interest, NOT APPLICABLE, since 01/01/2015
• DWD TX HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 01/01/2015
• JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC — indirect ownership interest, NOT APPLICABLE, since 01/01/2015
• LIBERTY COUNTY HOSPITAL DISTRICT NO 1 — 5% or greater direct ownership interest, 100%, since 11/30/2014
• LIBERTY COUNTY HOSPITAL DISTRICT NO 1 — operational/managerial control, NOT APPLICABLE, since 01/01/2015
• LIBERTY COUNTY HOSPITAL DISTRICT NO 1 — adp of the snf, NOT APPLICABLE, since 03/21/2025
• REG HG OPCO 1, LLC — indirect ownership interest, NOT APPLICABLE, since 01/01/2015
• REG HG OPCO LLC — indirect ownership interest, NOT APPLICABLE, since 01/01/2015
• REG MASTER TENANT II, LLC — adp of the snf, NOT APPLICABLE, since 01/01/2015
• REG OPERATOR HOLDCO LLC — indirect ownership interest, NOT APPLICABLE, since 01/01/2015
• REGENCY IHS CLINICAL CONSULTING, LLC — adp of the snf, NOT APPLICABLE, since 01/01/2015
• REGENCY IHS OF JEFFERSON LLC — direct ownership interest, NOT APPLICABLE, since 01/01/2015
• REGENCY IHS OF JEFFERSON LLC — adp of the snf, NOT APPLICABLE, since 03/21/2025
• REGENCY IHS OF JEFFERSON LLC — operational/managerial control, NOT APPLICABLE, since 01/01/2015
• REGENCY IHS REHAB LLC — adp of the snf, NOT APPLICABLE, since 01/01/2015
• REGENCY INTEGRATED HEALTH SERVICES LLC — operational/managerial control, NOT APPLICABLE, since 01/01/2015
• REGENCY INTEGRATED HEALTH SERVICES LLC — adp of the snf, NOT APPLICABLE, since 03/21/2025
• REGENCY TEXAS HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 01/01/2015