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 Jerome Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls was identified as high risk for falls upon admission, but the facility did not initiate a fall care plan or implement fall prevention interventions until after the resident suffered a significant fall injury requiring surgery. The care plan was only developed following the incident, contrary to facility policy.
Multiple residents reported that hot food was often served cold, and direct temperature checks confirmed that meals were below the required 135°F at the point of service. The Food Services Director acknowledged that food temperatures dropped during transport from the kitchen to the units, resulting in noncompliance with facility policy for hot food holding temperatures.
A resident with a history of psychosocial issues made a statement about trying to jump out the window, but the LPN did not notify supervisory staff, the social worker, or medical providers as required by policy. The required suicide precautions and psychiatric consult were delayed, and the care plan was not updated until after the incident was identified by surveyors.
A resident with severe cognitive impairment and multiple comorbidities was confined to their room and denied participation in activities after their roommate tested positive for RSV, despite having no symptoms or physician order for isolation. Staff physically blocked the resident from leaving the room, and leadership could not identify guidance supporting this practice for asymptomatic roommates. The resident experienced reduced engagement and increased napping, and the facility failed to recognize this as involuntary seclusion.
A resident with advanced dementia and significant care needs was found with an unexplained bruise on the forehead. Staff suspected the injury may have occurred during a mechanical lift transfer, but no one witnessed the event and the resident could not explain it. Facility documentation did not indicate that the injury was reported to the state agency, despite policy requiring immediate reporting of injuries of unknown source. Interviews with the DON and Administrator confirmed the reporting failure.
A resident with advanced dementia and significant care needs was found with an unexplained bruise on the forehead. The facility did not complete a thorough investigation or summary as required, failing to obtain statements from all staff involved and lacking documentation to determine the cause of the injury.
A resident admitted with a history of homicidal ideation and other medical conditions did not have psychosocial concerns or behaviors addressed in the baseline care plan within the required timeframe. Despite prior documentation of behavioral risks and a subsequent incident where the resident attempted to jump out a window, the care plan failed to include necessary interventions for psychosocial needs.
A resident with severe cognitive impairment and high fall risk did not have floor mats placed on both sides of the bed as ordered by the physician and outlined in the care plan. Observations found that only one mat was in place, with the other mat left folded against the wall. Staff interviews confirmed the mats were not consistently positioned after meals, and the DON acknowledged the requirement for both mats to be in place but could not explain the failure.
A resident with a history of mental health issues, including homicidal ideation and depression, was not promptly assessed or provided psychiatric services after making a statement about trying to jump out a window. Facility staff did not follow suicide precaution policies, including timely notification of supervisory staff and psychiatric services, or implementation of required safety checks.
A pharmacist did not identify or report missing behavioral monitoring and overdue AIMS assessments for a resident with dementia and other psychiatric diagnoses who was receiving an antipsychotic medication. Despite monthly medication regimen reviews and facility policy requiring regular monitoring, the pharmacist's reports failed to recommend necessary assessments or documentation.
Surveyors observed that large vents in two common areas contained significant dark-colored debris, indicating that regular cleaning by housekeeping staff, as required, had not been performed.
A resident with a history of mobility issues and osteoporosis fell and fractured their leg due to the failure of a nurse aide to use a gait belt during ambulation, as required by the facility's policy. The resident's care plan specified the use of a gait belt and walker, but the aide did not adhere to this, leading to the incident.
Failure to Initiate Fall Care Plan for High-Risk Resident
Penalty
Summary
A resident with a history of left artificial hip joint, type II diabetes, and Alzheimer's disease was admitted to the facility and identified as needing assistance with activities of daily living due to physical and mental impairments. The resident was assessed as a high risk for falls based on a fall risk assessment score of eighteen and had a documented fall in the month prior to admission. Despite these findings, the facility did not initiate a fall care plan or implement specific fall prevention interventions at the time of admission or upon identification of high fall risk. The lack of a fall care plan persisted until after the resident experienced a fall resulting in a right knee femur fracture, which required surgical repair. The care plan addressing fall risk and related interventions was only created following this incident. Facility documentation and interviews confirmed that the Director of Nursing was unaware that a fall risk care plan had not been implemented, despite facility policy requiring such a plan for residents identified as high risk for falls.
Failure to Serve Hot Foods at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that hot foods were served at appropriate temperatures for palatability, as evidenced by multiple resident interviews and direct temperature measurements. Several residents reported that their food was sometimes or often served cold, and one resident noted that the food did not taste good. The Food Services Director described the process for maintaining food temperature, which included taking and recording temperatures in the kitchen, using plate warmers, and covering plates with metal meal covers. A review of the temperature logs showed that temperatures met the food code standard when measured in the kitchen. However, during a test tray observation, food plated in the main dining room and delivered to a unit was found to be below the required temperature of 135 degrees Fahrenheit. Specifically, the internal temperatures of meatballs, spaghetti, and green beans ranged from 115 to 121.3 degrees Fahrenheit when measured upon delivery to residents. The Food Services Director acknowledged that the food temperatures were low due to the time taken for food to travel from the plating area to the unit. Facility policy required hot foods to be held at 135 degrees Fahrenheit or greater, which was not met at the point of service.
Failure to Notify Providers and Initiate Suicide Precautions After Resident's Suicidal Statement
Penalty
Summary
A deficiency occurred when the facility failed to notify the social worker, physician, and psychiatrist after a resident made a statement indicating suicidal ideation. The resident, who had a history of homicidal ideation, sepsis, chronic heart failure, and muscle weakness, was admitted following a hospital stay where psychosocial concerns had already been identified. Upon admission, the resident was noted to be cognitively intact but dependent on staff for many activities and had reported feeling down or hopeless in the two weeks prior. On one occasion, a nurse found the resident on the floor next to the bed, and the resident stated they were trying to jump out the window. Despite this statement, there was no documentation of further assessment by a charge nurse or notification of supervisory staff, social services, or medical providers as required by facility policy. The facility's policy required immediate notification and specific interventions, such as 15-minute checks or 1:1 observation, when a resident made suicidal statements. However, the LPN involved did not notify anyone, interpreting the resident's statement as a desire to go home rather than a suicidal intent. Interviews with staff confirmed that the required notifications and interventions were not initiated, and the psychiatric consult was not requested until three days after the incident. The social worker and APRN were not informed of the resident's statement, and the care plan addressing the behavior was only developed after surveyor inquiry.
Resident Confined to Room Without Symptoms or Physician Order Following Roommate's RSV Diagnosis
Penalty
Summary
A resident with severe cognitive impairment, ischemic cardiomyopathy, adjustment disorder, dementia, and stage 3 chronic kidney disease was placed on contact and droplet precautions after their roommate tested positive for RSV. Despite not exhibiting any symptoms of RSV and lacking a physician's order for isolation or testing, the resident was confined to their room. Observations showed the resident seated behind a privacy curtain, without access to engaging activities, and eating alone, while the roommate's television was playing. Facility staff, including nurse aides and LPNs, confirmed that the practice was to keep both the infected resident and their roommate on precautions, restricting the roommate from leaving the room even when asymptomatic. Staff physically blocked the resident from exiting the room and redirected them to remain seated behind the curtain. The recreation staff noted a decline in the resident's activity and increased napping, which was not reported to nursing or social services. The resident, who was typically active, was not allowed to participate in social or recreational activities during this period. Interviews with facility leadership, including the DON and infection control nurse, revealed that the policy was to confine all roommates of RSV-positive residents to their rooms, regardless of symptoms or mask compliance. The infection control nurse could not identify CDC guidance supporting this practice for asymptomatic roommates. The facility's policies required isolation to be the least restrictive possible and defined abuse to include unreasonable infliction of confinement. However, the resident was kept in their room without evidence of infection or a physician's order, and the facility failed to recognize this as involuntary seclusion.
Failure to Report Injury of Unknown Source to State Agency
Penalty
Summary
A resident with diagnoses including dementia, psychosis, restlessness, and agitation, who was severely cognitively impaired and dependent on staff for transfers and mobility, was found with a bruise on the forehead measuring 5.0 cm by 3.5 cm. The injury was discovered during a nurse's assessment, and there were no witnesses to the incident. The resident was unable to communicate how the injury occurred, and staff suspected it may have resulted from contact with the mechanical lift during a transfer, but this could not be confirmed. Documentation indicated that two staff had assisted with the transfer, but neither observed the injury occur or noticed any signs of injury immediately after the transfer. Facility documentation, including a Reportable Event Report and progress notes, classified the incident as not requiring reporting to the state agency, and the section indicating state agency notification was left blank. Interviews with the DON and Administrator confirmed that the injury was of unknown source and should have been reported to the state agency, as required by facility policy and regulations. The facility's policy defined an injury of unknown source as one not observed by any person or not explainable by the resident, and directed that such incidents be reported immediately to the state agency. Despite internal discussions and review of witness statements, there was no documentation or evidence to validate that the origin of the bruise was known or witnessed. The failure to report the injury of unknown source to the state agency constituted a deficiency, as the facility did not follow its own policy or regulatory requirements for reporting suspected abuse, neglect, or injuries of unknown source.
Incomplete Investigation of Injury of Unknown Source
Penalty
Summary
The facility failed to ensure a complete investigation and summary were completed for a resident with an injury of unknown source. A resident with diagnoses including dementia, psychosis, restlessness, and agitation, who was severely cognitively impaired and dependent on staff for transfers and mobility, was found with a significant bruise on the forehead. The injury was unwitnessed, and the resident was unable to communicate how it occurred. Although staff suspected the mechanical lift may have been involved during a transfer, the nurse aide who assisted with the transfer did not observe any injury at the time and did not witness the resident's head being struck. The Director of Nursing Services (DNS) obtained some staff statements but did not collect a statement from the second nurse aide involved in the transfer. Additionally, the DNS did not complete a summary of the investigation, mistakenly believing the cause of the bruise was known and witnessed, despite a lack of documentation or statements to support this. The facility's policy required a thorough investigation and documentation for injuries of unknown source, but this was not completed as directed.
Failure to Address Psychosocial Needs in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission that addressed a resident's psychosocial and behavioral needs, specifically homicidal ideation documented prior to admission. The resident was admitted with diagnoses including homicidal ideation, sepsis, heart failure, and muscle weakness. Hospital records indicated the resident had made comments about homicidal ideation, and the hospital had taken precautions by withholding potentially dangerous items. Despite this, the facility's baseline care plan, created three days after admission, did not include any psychosocial concerns or behaviors, and psychiatry services at the facility were not updated regarding the resident's prior psychosocial behavior. A nursing note several days after admission documented an incident where the resident was found on the floor next to the bed, stating an attempt to jump out the window. The baseline care plan policy required a resident-centered plan within 48 hours of admission, including necessary healthcare information. However, the resident's care plan did not reflect the known psychosocial risks, and staff interviews confirmed that the baseline care plan should have addressed these issues but did not, as the resident had no prior behavioral incidents during a previous admission.
Failure to Consistently Place Fall Mats as Ordered for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that floor mats were in place on both sides of the bed for a resident with dementia, hypotension, and mobility abnormalities, who was assessed as high risk for falls. The resident's care plan and physician's order specifically directed that floor mats be placed on both the left and right sides of the bed every shift. Despite these orders, observations on multiple occasions found that only one floor mat was in place, with the other mat folded and leaning against the wall. The resident was bedfast and required extensive assistance for transfers and bed mobility, and was dependent with toileting. Interviews with nurse aides and an LPN confirmed that the floor mat was not consistently placed on the window side of the bed after meals, as required. The nurse aide referenced the need to check the care card on the computer, as it was not posted in the resident's room, and acknowledged the oversight. The LPN also recognized the failure to ensure both mats were in place. The Director of Nursing Services confirmed that both nurses and nurse aides were responsible for mat placement but could not explain why the intervention was not implemented as ordered. Facility policy required that fall prevention interventions be implemented according to assessed risk, but this was not followed in this case.
Failure to Provide Timely Psychiatric Intervention and Follow Suicide Precaution Policy
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed psychosocial behaviors and had a history of mental health concerns, including homicidal ideation and depression. Upon admission, the resident had documented psychiatric issues from the hospital, including emotional distress and statements about self-harm, which led to a referral for psychiatric services. Despite this, psychiatric services at the facility were not promptly notified or updated regarding the resident's psychosocial behavior, and the resident was not seen by psychiatry in a timely manner. A significant event occurred when the resident was found on the floor next to their bed and stated they were trying to jump out the window. The nursing note documenting this incident did not include further assessment by a charge nurse or documentation that supervisory staff, social services, or medical providers were notified. The responsible LPN did not interpret the statement as suicidal and therefore did not follow facility policy, which required 15-minute checks, close observation, and notification of appropriate staff for suicidal statements. Interviews with facility staff confirmed that the required procedures for managing suicidal statements were not followed. The nursing supervisor, social worker, and advanced practice registered nurse were not notified of the resident's statement, and psychiatric services were not engaged until several days after the incident. Facility policies required immediate assessment, notification, and safety interventions for residents expressing suicidal ideation, but these steps were not taken in this case.
Pharmacist Failed to Identify Missing Behavioral Monitoring and AIMS Assessments for Antipsychotic Use
Penalty
Summary
A deficiency occurred when the facility's consulting pharmacist failed to identify and report irregularities in the medication regimen review for a resident receiving an antipsychotic medication. The resident, who had diagnoses including dementia, adjustment disorder with depressed mood, and anxiety disorder, was severely cognitively impaired and dependent on staff for several activities of daily living. The resident's care plan and physician's orders indicated ongoing use of Risperidone, an antipsychotic, and required behavioral monitoring and regular AIMS (Abnormal Involuntary Movement Scale) assessments every six months. However, behavioral monitoring was not documented on the Medication Administration Record (MAR) after a certain date, and no AIMS assessment was completed for over 14 months, despite the continued administration of the antipsychotic medication. The consulting pharmacist conducted monthly medication regimen reviews but did not recommend the completion of overdue AIMS assessments or the resumption of behavioral monitoring, even though these omissions were evident in the clinical record and psychiatric progress notes. Facility policy required adherence to CMS guidelines and current practice standards, including maintaining consultant pharmacist reports and ensuring appropriate pharmaceutical care. Despite these requirements, the pharmacist's consultation reports failed to address the lack of behavioral monitoring and overdue AIMS assessments, contributing to the deficiency.
Failure to Maintain Clean Vents in Common Areas
Penalty
Summary
During observations of two common areas, surveyors identified that large vents located in the North and East units were not maintained in a clean condition. The vents, each measuring approximately 2.5 feet by 5.0 feet, were found to have a significant amount of dark-colored debris within the slats and inside the vents. Interviews with the Director of Facilities confirmed that housekeeping staff were responsible for cleaning the vents and that the vents were supposed to be vacuumed weekly, but this cleaning had not occurred as required.
Failure to Use Gait Belt Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to utilize a gait belt when assisting Resident #1, who required staff assistance for ambulation, resulting in a fall and subsequent fractures. Resident #1 had a history of acute respiratory failure, weakness, difficulty walking, osteoporosis, and generalized osteoarthritis. The resident's care plan specified the use of a gait belt and a two-wheeled walker for ambulation with staff assistance. However, on the day of the incident, the nurse aide did not use a gait belt while assisting the resident from the bathroom to the bed, leading to the resident leaning to the left and being lowered to the floor, resulting in a left leg fracture. The facility's policy mandates the use of gait belts for all resident transfers and ambulation requiring assistance, which the nurse aide had acknowledged understanding. Despite this, the nurse aide did not adhere to the policy, contributing to the resident's fall. The Director of Nursing confirmed the policy requirement and the failure to use the gait belt during the incident. The facility's fall prevention policy also emphasizes the use of gait belts, underscoring the deficiency in following established safety protocols.
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 892 citations issued within 25 miles in the last 12 months — including the 9 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 New Britain
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monsignor Bojnowski Manor | 1 mi | ★★★★★ | 3 | 0 |
| Grandview Rehabilitation And Healthcare Center | 1 mi | — | 14 | 1 |
| Ledgecrest Health Care Center | 2.9 mi | ★★★★★ | 4 | 0 |
| Apple Rehab Farmington Valley | 3 mi | ★★★★★ | 1 | 0 |
| Civita Care Center At Newington | 3.4 mi | ★★★★★ | 42 | 1 |
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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.