Below 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 Jeffersonville Care Center Llc during CMS and state inspections, most recent first.
A resident with schizophrenia, severe cognitive impairment, traumatic brain injury, and documented aggressive behaviors physically assaulted another severely cognitively impaired resident who had no documented behavioral issues. The aggressive resident’s care plan identified risk for behavior problems and called for monitoring and behavioral interventions, yet he was able to engage in an altercation in which the other resident was found on the floor with the aggressor standing over him, flailing his arms. The injured resident sustained a scalp laceration and rib contusion. The DON reported there had been a previous incident between the same two residents and acknowledged not initially recognizing the severity of that earlier event, and the aggressive resident was not placed on 1:1 supervision but only on behavioral monitoring.
A resident with significant cognitive impairment and multiple diagnoses reported that a man had touched her private area, and hospice staff observed unexplained bruises on her back and shoulders. Hospice personnel relayed the bruises and allegation to facility staff, including a CMA, LPNs, and the DON, and the resident’s family was also informed and later saw bruises that staff could not explain. Although the facility’s abuse policy required prompt reporting of such allegations and injuries to the state agency, the DON and Administrator, after consulting with a corporate representative, did not report the injury of unknown origin or the alleged sexual abuse to the State Survey Agency.
The facility failed to maintain a homelike environment in three resident rooms, with issues such as holes in walls, discolored ventilation covers, and missing window coverings. The Maintenance Director, new to the facility, confirmed these unacceptable conditions.
A facility failed to provide adequate ADL care for a resident with Huntington's Disease, major depressive disorder, and anxiety, who was dependent on staff for personal hygiene. Observations showed the resident had unshaven facial hair despite the facility's policy requiring grooming services for residents unable to perform ADLs. Staff interviews revealed that male residents were expected to be shaved on bath days, but this was not consistently done, leading to potential risks for the resident.
A facility failed to follow professional standards during tracheostomy care for a resident with respiratory failure. An LPN removed the old tracheostomy ties before applying new ones, leaving the tracheostomy tube unsecured. The DON stated that the tracheostomy should be secured at all times to prevent dislodgement and ensure the resident's breathing ability.
A medication bubble card containing azithromycin was found unsecured at a nurse's station, accessible to residents and unauthorized individuals. The DON confirmed the lapse, and an LPN suggested the card might have slid from the medication cart, indicating a failure to adhere to the facility's medication storage policy.
The facility failed to follow infection control processes, as a CNA did not change gloves or sanitize hands between caring for two residents, and an LPN did not perform hand hygiene between glove changes during tracheostomy care for a resident with respiratory failure. Both staff members acknowledged the lapses, and the DON and IP emphasized the importance of hand hygiene to prevent cross-contamination.
Failure to Prevent Resident-on-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite having policies requiring prevention of abuse, neglect, and exploitation. The facility’s abuse policy called for identifying, correcting, and intervening in situations where abuse was more likely to occur, including deploying sufficient trained staff who know residents’ care needs and behavioral symptoms. One resident with severe cognitive impairment, schizophrenia, severe intellectual disabilities, a history of traumatic brain injury, and documented physical and verbal behaviors toward others had a care plan identifying risk for behavior problems, including verbal behaviors and aggression. The care plan interventions included administering psychotropic medications as ordered, providing positive interactions, diverting attention to minimize disruptive behaviors, and observing and documenting target behavioral symptoms such as aggression or violence toward others. Despite these identified risks and interventions, the resident with behavioral symptoms was involved in an altercation with another severely cognitively impaired resident who did not have documented behavioral issues during the assessment period. On the date of the incident, a nurse heard a loud noise and yelling and, upon responding, found the resident with behavioral symptoms standing over the other resident, flailing his arms, while the other resident was sitting on the floor. The documentation indicated that the resident on the floor had incurred injuries as a result of this altercation. The incident demonstrated that the resident known to have aggressive behaviors was able to physically assault another resident. The injured resident had been admitted with dementia and other conditions including psychotic disturbance, mood disturbance, anxiety, and delirium due to a known physiological condition, and had a BIMS score indicating severe cognitive impairment but no documented behaviors during the assessment period. Following the altercation, this resident was found to have a scalp laceration, red discoloration around the right eye, and complaints of right-sided pain, later diagnosed as a scalp laceration and right rib contusion. The DON acknowledged a previous incident between the same two residents and stated that she did not initially recognize the severity of that incident until reviewing documentation later, and that the resident with behavioral symptoms was not placed on 1:1 supervision but instead on behavioral monitoring, indicating that closer protective measures were not implemented despite known behavioral risks and a prior incident between the same residents.
Failure to Timely Report Injury of Unknown Origin and Alleged Sexual Abuse
Penalty
Summary
The facility failed to follow its Abuse, Neglect and Exploitation policy requiring timely reporting of alleged violations to the administrator, state agency, and other authorities. The policy specified that allegations involving abuse or serious bodily injury must be reported immediately, but no later than two hours after the allegation, and other events within 24 hours. A resident with anoxic brain damage, seizure disorder, psychosis, anxiety disorder, memory problems, and severely impaired decision-making reported that a man had touched her private area. Hospice staff, including a CNA and Social Worker, observed bruises on the resident’s back and shoulders and were informed by the resident that someone had touched her inappropriately. These concerns were communicated to facility staff, including a CMA, LPNs, and the DON. The hospice agency notified the resident’s family that the resident had bruises and had reported inappropriate touching, and the family later observed bruises that facility staff could not explain. Hospice CNA DD reported the bruises and allegation to the Hospice Administrator and an LPN at the facility. The Hospice Social Worker reported the bruises and allegation to the facility CMA and DON. The CMA assessed the bruises and reported them to an LPN but did not report the allegation to the Administrator. The LPN reported the bruising to the DON and Administrator. The DON acknowledged being notified in January of the bruises and the allegation of inappropriate touching and stated she discussed these with the Administrator and a Corporate Consultant, who advised that the incidents should not be reported. As a result, the injury of unknown origin and the allegation of sexual abuse were not reported to the State Survey Agency as required by the facility’s policy.
Deficient Maintenance in Resident Rooms
Penalty
Summary
The facility failed to provide a homelike environment for residents in three of 17 rooms on one of five halls, as observed during a survey. The Preventative Maintenance Program policy, dated 4/1/2024, assigns the Maintenance Director the responsibility of ensuring the maintenance of buildings, grounds, and equipment in a safe and operable manner. However, observations revealed several deficiencies: holes in the sheetrock wall near the baseboard in one room, a discolored and substance-covered ventilation cover in the hallway, and an orange-brownish substance at the sink's drainage area in another room. Further observations identified additional issues, including a room lacking window coverings and a shared bathroom with a sink missing faucet hardware, resulting in continuously running water. During interviews, the Administrator, Maintenance Director, and Maintenance Assistant confirmed these findings. The Maintenance Director, who had been at the facility for only two days, acknowledged the unacceptable conditions of the rooms.
Failure to Provide Adequate ADL Care for Resident
Penalty
Summary
The facility failed to provide adequate ADL care, specifically the shaving of facial hair, for a resident identified as R81. This resident was diagnosed with Huntington's Disease, major depressive disorder, and anxiety, and was documented as being dependent on staff for showering and personal hygiene. Observations over three consecutive days revealed that R81 had unshaven facial hair approximately one-fourth of an inch long. The facility's policy on ADLs, revised in April 2025, mandates that residents unable to perform activities of daily living should receive necessary services to maintain grooming and personal hygiene. Interviews with facility staff, including an LPN and a CNA, indicated that male residents were expected to be shaved on their scheduled bath days, which occurred three times a week. However, it was confirmed that R81, despite having received a shower on a recent bath day, was not shaved. The LPN noted that R81 occasionally refused baths but had not done so recently, and the CNA acknowledged that men were not always shaved during showers. This oversight in care had the potential to place R81 at risk for skin care issues and affect the resident's self-esteem regarding their appearance.
Failure to Secure Tracheostomy During Care
Penalty
Summary
The facility failed to adhere to professional standards of practice during tracheostomy care for a resident, identified as R56, who was receiving tracheostomy care. The resident had a medical history that included acute and chronic respiratory failure with hypoxia. The care plan for R56 included interventions such as providing oxygen, humidity, tracheostomy care, and tubing changes as indicated by physician's orders. However, during an observation of tracheostomy care, an LPN removed the resident's tracheostomy ties without first applying new ties, leaving the tracheostomy tube unsecured. The Director of Nursing (DON) stated that the expected procedure was to secure the tracheostomy with new ties before removing the old ones to prevent the tube from being dislodged. The LPN confirmed that she had removed the old ties before applying the new ones, which left the tracheostomy unsecured and could potentially compromise the resident's air supply. This action was contrary to the facility's policy and the DON's expectations, which emphasized the importance of securing the tracheostomy at all times to ensure the resident's breathing ability was not compromised.
Medication Storage Deficiency at Nurse's Station
Penalty
Summary
The facility failed to secure and store medication properly at one of its nurse's stations, specifically Station 100/200. During an observation, a medication bubble card containing oral azithromycin was found lying unsecured and unsupervised on the outer counter ledge of the nurse's station. This area was accessible to residents and unauthorized individuals, as evidenced by the presence of one ambulatory and one wheelchair-bound resident in the vicinity of the medication. The medication was not under the direct observation of any nursing staff at the time of the observation. Interviews conducted with the Director of Nursing (DON) and an LPN revealed that the medication was expected to be secured in the medication cart or locked in the medication room at all times. The DON confirmed the medication was left unsecured and stated that nursing staff should maintain direct eye contact with their medication carts. The LPN involved in the medication pass explained that the medication bubble card might have accidentally slid from the medication cart onto the countertop, indicating a lapse in following the facility's medication storage policy.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to adhere to its infection control processes, specifically in hand hygiene practices, as observed on Hall 400 and during tracheostomy care for a resident. A Certified Nursing Assistant (CNA) was observed providing care to two different residents without changing gloves or performing hand hygiene between residents. The CNA acknowledged the oversight and recognized that such actions could lead to the spread of germs between residents. The Director of Nursing (DON) and the Infection Preventionist (IP) both confirmed that the facility's policy required staff to sanitize their hands between resident care and change gloves to prevent cross-contamination. Additionally, during tracheostomy care for a resident with acute and chronic respiratory failure, a Licensed Practical Nurse (LPN) did not perform hand hygiene between glove changes. The LPN removed the inner cannula, changed gloves without sanitizing hands, and used an ungloved hand to hold the tracheostomy tube. The DON and IP reiterated the importance of hand hygiene in preventing infection, especially during sterile procedures like tracheostomy care. The LPN admitted to not following proper hand hygiene protocol, which could risk infection due to cross-contamination.
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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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Nursing homes near Jeffersonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Toomsboro | 17.4 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Warner Robins Llc | 18 mi | ★★★★★ | 2 | 0 |
| Pruitthealth - Lakeside, Llc | 18.4 mi | ★★★★★ | 5 | 0 |
| Warner Robins Rehabilitation Center | 18.9 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - The Lodge, Llc | 19.1 mi | ★★★★★ | 7 | 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.