Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jefferson House during CMS and state inspections, most recent first.
The facility failed to submit PBJ data on time for two consecutive quarters in 2024 due to a staffing change, resulting in a 1-star rating and suppression of the weekend staffing metric. The Administrator has since taken responsibility for the submissions.
The facility failed to document a new pressure ulcer for a resident, did not implement padded side rails for another resident at risk of bruising, and neglected to schedule specialist appointments for two residents, leading to lapses in care and safety.
The facility failed to ensure proper use of beard restraints and hand hygiene during meal service, leading to cross-contamination. Dietary staff were observed with exposed facial hair and did not perform appropriate hand hygiene after handling raw meat. Additionally, open food items in storage were not properly labeled, and expired items were not discarded, violating facility policies.
A facility failed to properly disinfect a glucometer used for multiple residents by using expired disinfectant wipes, contrary to the manufacturer's instructions and facility policy. The deficiency involved residents with conditions such as Type 2 Diabetes and Alzheimer's disease, who required regular blood glucose monitoring. Nursing staff interviews revealed a failure to adhere to the policy of monitoring and disposing of expired cleaning supplies, leading to the use of ineffective wipes.
Two residents with herpes zoster/shingles had isolation signs on their doors that indirectly disclosed their medical conditions, breaching privacy. The signs, indicating 'NO ENTRY to persons who HAVE NOT HAD: the varicella/chicken pox vaccine or chicken pox,' were placed according to facility policy but failed to maintain confidentiality. Both residents expressed discomfort with the signage, and the Infection Preventionist could not justify how privacy was maintained.
Two residents experienced medication administration errors by an LPN. One resident was nearly given insulin without a physician's order, and another received an incorrect dose of Klonopin. The LPN failed to verify resident identity and medication details, contrary to facility policy.
The facility failed to provide proper pressure ulcer care for two residents. One resident, at moderate risk, did not receive the prescribed skin prep treatment, while another resident's heels were not properly offloaded, contrary to care plan instructions. Staff were unaware of proper procedures, leading to inadequate care and increased risk of pressure ulcers.
The facility failed to complete timely Quarterly MDS assessments for two residents. One resident with dementia and spinal stenosis had an assessment overdue by 72 days, while another with chronic systolic heart failure and type 2 diabetes had an assessment overdue by 60 days. An LPN acknowledged the oversight but could not explain the reason for the missed assessments.
The facility failed to transmit MDS assessments on time for several residents, with delays ranging from 5 to 42 days. These delays were due to staffing issues, as a new MDS Coordinator was catching up on work while other coordinators were on leave. The RAI manual requires quarterly assessments to be submitted within 14 days, a standard not met in these cases.
The facility failed to maintain cleanliness and sanitation in three nourishment room sinks. Observations revealed issues such as a green substance, leaks, rust, and debris under the sinks. The Director of Environmental Services and the Administrator acknowledged the need for cleaning and maintenance, but there was no preventive maintenance plan or policy in place. Environmental rounds did not include checking under sinks due to zip ties.
A resident's financial information was misappropriated by a nursing assistant who used the resident's bank account to pay personal debts. The resident, who was cognitively intact, had a blank check left in their drawer by family, which was accessed by the NA. The incident was reported to the police, and the facility's investigation revealed the NA had documentation showing she paid the bills after the fraudulent activity was flagged. The NA was suspended, and the case was pending legal review.
Late PBJ Submissions Lead to Deficiency
Penalty
Summary
The facility failed to submit Payroll Based Journal (PBJ) data on time for Quarter 1 and Quarter 2 of 2024, resulting in a deficiency. The issue arose when the staff member responsible for submitting the PBJ reports left the facility and later returned on a per diem basis, during which time the PBJ for Quarter 1 was not submitted on time. This delay subsequently triggered a late submission for Quarter 2 as well. As a result, the facility was identified with a 1-star rating, and the excessively low weekend staffing metric was suppressed for both quarters. The Administrator acknowledged the responsibility for reporting the PBJ and indicated that no further issues have been identified since taking over the task.
Failure to Document and Implement Physician Orders
Penalty
Summary
The facility failed to properly document and address a change in skin condition for a resident with a history of pressure ulcers, diabetes, and heart failure. A new pressure ulcer was identified by a registered nurse but was not documented with necessary details such as size and condition, nor was the provider notified for treatment. This oversight was discovered during an interview with another nurse who was unaware of the new ulcer, and the nurse manager confirmed that the facility's policy for documenting skin integrity changes was not followed. Another deficiency involved a resident with cognitive decline and a history of embolism and thrombosis, who was at risk for bruising and bleeding due to anticoagulant therapy. The facility failed to implement a physician's order for padded side rails, as the pads were found unused in the resident's room. The nurse and nursing assistant were unaware that the pads did not fit the new beds, and the assistant director of nursing was not informed of the issue, leading to a lack of necessary safety measures for the resident. Additionally, the facility did not schedule necessary specialist appointments for two residents. One resident, with a history of heart failure and an implanted defibrillator, requested to see their cardiologist but was not scheduled for an appointment due to miscommunication and lack of documentation. Another resident with anemia had a physician's order for a hematology consult that was not transcribed or scheduled, leaving the resident without necessary follow-up for abnormal blood work results. These failures highlight significant lapses in communication and adherence to physician orders within the facility.
Improper Beard Restraint and Hand Hygiene in Dietary Department
Penalty
Summary
The facility failed to ensure proper use of beard restraints and hand hygiene during meal service. Dietary Aide #1 and the Executive Chef were observed with beard restraints that did not fully cover their facial hair, exposing the sides of their beards. Despite attempts to readjust the restraints, both continued to handle food with exposed facial hair. The Executive Chef also failed to perform appropriate hand hygiene after touching his face and raw hamburger meat, leading to cross-contamination when he handled a hamburger bun without changing gloves or washing his hands. In the dry goods storage area, the facility did not properly secure and label open food items. A partially opened bag of flour and a bag of cornmeal were found without labels indicating the date opened or expiration date. Additionally, the floor beneath the flour bag had debris that had not been discarded. The Director of Food Services acknowledged these issues, noting that the bags should have been secured and dated, and the debris should have been removed. Expired food items were also found in the storage area, including containers of spices and plant-based coconut milk that were past their expiration dates. The Director of Food Services confirmed that these items had not been in use and should have been discarded. The facility's policies on uniform dress code, food handling, glove use, and storage supply were not adhered to, contributing to the deficiencies observed during the survey.
Improper Disinfection of Glucometer with Expired Wipes
Penalty
Summary
The facility failed to properly clean and disinfect a glucometer device according to the manufacturer's instructions, as observed in the care of five residents who required blood glucose testing. The deficiency was identified when a registered nurse was seen using expired disinfectant wipes to clean the glucometer, which was used for multiple residents. The expired wipes had been in use for over four months, and the nurse did not check the expiration date before using them, contrary to the facility's policy. The residents involved in this deficiency had various medical conditions, including Type 2 Diabetes, Alzheimer's disease, chronic kidney disease, and other health issues. They required regular blood glucose monitoring as per physician orders. The facility's policy required glucometers to be disinfected before and after each use to prevent the transmission of infectious diseases, but this was not adhered to due to the use of expired disinfectant wipes. Interviews with the nursing staff revealed a lack of adherence to the facility's policy on monitoring and disposing of expired cleaning supplies. The responsibility to ensure the wipes were not expired was placed on the nurses, but this was not effectively managed, leading to the continued use of ineffective disinfectant wipes. The deficiency was further confirmed by the Disinfectant's Professional Customer Care Center, which stated that expired wipes could not guarantee proper disinfection and recommended their immediate disposal.
Privacy Breach Due to Inappropriate Isolation Signage
Penalty
Summary
The facility failed to ensure the privacy of residents' medical information by posting isolation signs that identified the type of infection, specifically herpes zoster/shingles, on the doors of two residents. Resident #87, who was diagnosed with herpes zoster/shingles, had an isolation sign on the door that indicated 'NO ENTRY to persons who HAVE NOT HAD: the varicella/chicken pox vaccine or chicken pox.' This sign was visible during observations on multiple occasions, and both Resident #87 and another individual expressed discomfort with the sign, indicating it made the room appear quarantined. Similarly, Resident #353, who also had a diagnosis of herpes zoster/shingles, had the same type of isolation sign on the door. Observations confirmed the presence of the sign, and Resident #353 expressed the need to explain the condition to visitors due to the sign's presence. The facility's Infection Preventionist confirmed that the signs were placed according to facility policy, which was consistent across all company locations. However, the Infection Preventionist could not explain how the signs maintained privacy, as they indirectly revealed the residents' diagnoses. The facility's policies on contact and airborne precautions for herpes zoster, as well as enhanced barrier precautions, were reviewed. These policies directed that patients with localized shingles should be placed on standard precautions with 'No Entry' signage, ideally in a single room. Despite these guidelines, the signage used did not adequately protect the residents' privacy, as it indirectly disclosed their medical conditions to anyone who could interpret the sign's meaning.
Medication Administration Errors by LPN
Penalty
Summary
The facility failed to adhere to professional standards for medication administration, as evidenced by two separate incidents involving residents. In the first incident, a resident who was cognitively intact and had no physician orders for insulin was nearly administered an insulin injection by an agency LPN. The resident questioned the LPN's actions, which led to the LPN leaving the room without verifying the resident's identity through the name bracelet or other means. The LPN later claimed that the insulin was intended for another resident, but this was not verified before attempting the injection. In the second incident, another resident with cognitive impairments and behavioral disturbances was administered an incorrect dose of Klonopin by the same LPN. The physician's order specified a 0.5 mg dose, but the LPN administered only 0.25 mg. The LPN was unaware of this medication error, which was later documented by the facility. The facility's policies on medication administration and error prevention were not followed, as the LPN did not verify the correct medication, dose, or resident identity. Interviews with facility staff and documentation revealed that the LPN had been feeling ill and was involved in multiple medication errors on the same day. The facility's policies require verification of the right medication, dose, route, time, and resident identity, which were not adhered to in these incidents. The facility took steps to address the situation by contacting the staffing agency and documenting the errors, but the deficiencies highlight a failure to follow established protocols for safe medication administration.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for two residents, leading to deficiencies in their care. Resident #8, who had a history of rheumatoid arthritis, contractures, and osteoarthritis, was at moderate risk for pressure ulcers. Despite a physician's order to apply skin prep to both heels twice daily, a nurse applied a personal moisturizer instead, failing to follow the prescribed treatment. This oversight was acknowledged by the nurse during a review of the clinical record, indicating a lapse in adhering to the physician's orders. Resident #39, diagnosed with osteoarthritis, osteoporosis, and hypertension, was also at risk for pressure ulcers due to non-ambulatory status. The care plan required offloading the heels while in bed, but observations revealed that the resident's heels were not properly offloaded, as they were resting directly on the bed. A flat pillow was used under the calves, which did not elevate the heels as required. A nurse and a nurse aide were unaware of the proper offloading technique, leading to the resident's heels not being adequately protected from pressure. The facility's policy on skin integrity and pressure ulcer prevention was not followed in both cases. The failure to adhere to physician orders and facility protocols resulted in inadequate care for the residents, potentially compromising their skin integrity and increasing the risk of pressure ulcers. The staff's lack of knowledge and understanding of the care requirements contributed to these deficiencies.
Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete Quarterly Minimum Data Set (MDS) assessments in a timely manner for two residents. Resident #49, diagnosed with dementia and spinal stenosis, had a quarterly MDS assessment completed on 8/16/24, but no further assessments were completed, with the next due assessment in November 2024 being 72 days overdue. Similarly, Resident #89, with chronic systolic heart failure and type 2 diabetes mellitus, had a quarterly MDS assessment completed on 8/28/24, but the subsequent assessment due in November 2024 was 60 days overdue. MDS Coordinator #2, an LPN, acknowledged that both residents were listed on the November 2024 MDS calendar for assessment completion but could not provide a reason for the oversight. According to the Resident Assessment Instrument (RAI) Manual, the facility is required to complete a Quarterly MDS assessment every three months.
Delayed MDS Transmissions Due to Staffing Issues
Penalty
Summary
The facility failed to ensure timely transmission of Minimum Data Set (MDS) assessments for four sampled residents, leading to deficiencies in compliance with regulatory requirements. Resident #49 had an annual MDS assessment completed but transmitted 5 days late, and a quarterly assessment transmitted 19 days late. Resident #52 experienced significant delays with a quarterly assessment transmitted 42 days late and another 23 days late. Resident #89 had a quarterly assessment transmitted 12 days late and an annual assessment 6 days late. Resident #96's admission MDS was transmitted 6 days late, and a quarterly assessment was 30 days late. The delays were attributed to staffing issues, as identified by MDS Coordinator #1, who was a newer employee and was catching up on work due to other coordinators taking time off. The Resident Assessment Instrument (RAI) manual requires that quarterly assessments be submitted within 14 days of completion, a standard that was not met in these cases. The facility's failure to adhere to these timelines resulted in the noted deficiencies.
Deficiency in Sanitation and Maintenance of Nourishment Room Sinks
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in three out of four nourishment room sinks, as observed during a tour with the Director of Environmental Services and the Administrator. On the first floor, a nourishment room cabinet was locked with a zip tie and contained a green substance at the bottom, which the Director of Environmental Services suggested was coming from the pipes. Another first-floor nourishment room had an unlocked door, and a container under the sink was collecting water with black particles, indicating a slow leak and possible rust. The Administrator confirmed that nothing should be stored under the sink, and items were removed. On the second floor, a nourishment room cabinet under the sink contained black debris, rust, and a mouse trap, with the Director of Environmental Services acknowledging the need for cleaning and maintenance. The Environmental Services Assistant reported not receiving any repair requests for the sinks, and the Administrator admitted there was no preventive maintenance plan for these areas. Additionally, RN #7 mentioned that environmental rounds do not include checking under sinks due to zip ties, and there was no facility policy available for maintenance and care under the sinks.
Misappropriation of Resident's Financial Information
Penalty
Summary
The facility failed to protect a resident from the wrongful use of their belongings, specifically their financial information. A resident, who was cognitively intact with a BIMS score of fifteen, had their bank account information misappropriated by a nursing assistant (NA) who did not work on the resident's unit. The resident's family had left a blank check in the resident's drawer for four days, during which time the NA allegedly used the resident's banking information to pay personal debts totaling approximately $1,900. The incident was reported to the local police by the resident's Power of Attorney, and the facility was notified of the fraudulent activity. The facility's investigation revealed that the NA had documentation showing she paid the bills in question after the fraudulent payments were flagged by the bank. Despite the NA's denial of the allegations, the police confirmed that the resident's account was used for the NA's bills. The facility's policies on protecting resident property and preventing misappropriation were not effectively implemented, as evidenced by the NA's access to the resident's financial information. The case was pending court and prosecutor review, and the NA was suspended during the investigation.
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What surveyors actually found near you
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bel-air Manor Nursing & Rehabilitation Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Civita Care Center At Newington | 2.4 mi | ★★★★★ | 42 | 1 |
| Avery Nursing Home/noble Building | 2.6 mi | ★★★★★ | 1 | 0 |
| Maple View Health & Rehabilitation Center | 3 mi | ★★★★★ | 1 | 0 |
| Autumn Lake Healthcare At New Britain | 3.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.