Above average — CMS composite of the measures below.
The next survey window likely opens around September 2026
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 Jnh-jefferson Inn during CMS and state inspections, most recent first.
Late Meal Service and Extended Overnight Interval: Staff failed to ensure meals were served at scheduled times for residents in one building. Breakfast was served about 2 hours late, and staff confirmed a non-diabetic resident could have gone almost 17 hours without a meal if a bedtime snack was not requested. The DO, FSA, and NHA all acknowledged late meal delivery and service, with the NHA stating meals should be served on time, hot, and appealing.
Improper Glove Use During Food Temperature Checks: During breakfast temperature checks, a dietary staff member opened a kitchen door while wearing gloves and then resumed taking food temperatures without removing the gloves, washing hands, or donning new gloves. The staff member acknowledged that hand hygiene and glove changes were needed after touching the door handle, and facility policy required safe food-handling and good personal hygiene during food prep and service.
Care Plan Did Not Address Dialysis Weight Monitoring: A resident with ESRD had a care plan focused on altered nutritional status and notifying the MD/RD of significant weight changes, but it did not include individualized interventions for ongoing dialysis needs, pre- and post-dialysis weight monitoring, communication with the dialysis clinic, or evaluation of fluid balance trends. The RN care plan nurse stated dialysis weights are important to show changes in the resident before and after dialysis.
Incomplete dialysis communication forms were not followed up for a resident with ESRD receiving routine HD. The resident had intact cognition, but the forms were missing pre- and post-dialysis weights on multiple occasions. RN staff said incomplete forms were assumed to have no issues, while the dialysis center stated missing information is normally requested by fax or email and had no record of such a request from the facility. The DON said staff lacked training in monitoring dialysis residents.
Missing Dialysis Weight Documentation: A resident with ESRD receiving routine dialysis had no documented pre- or post-dialysis weights on multiple dialysis communication forms. RNs stated facility staff assumed the dialysis clinic handled the weights or that missing entries meant no concerns, and the DON acknowledged staff lacked training on monitoring dialysis residents and completing the related documentation.
A resident with ESRD receiving routine hemodialysis had incomplete dialysis communication forms, with pre- and post-dialysis weights missing on multiple treatment days. Nursing staff and dialysis-clinic staff both expected the weights to be documented, but facility staff assumed missing entries meant there were no concerns and did not contact the dialysis center for the omitted information. The DON stated the facility was new to dialysis residents and staff lacked training on monitoring dialysis residents and completing related documentation.
Failure to use EBP during wound care: An LPN provided bilateral wound care to a resident with lower leg wounds without wearing a gown, despite facility policy and EBP signage requiring gloves and a gown for wound care. The LPN acknowledged the omission, and the DON and IP stated staff were expected to follow the posted precautions and that the resident was at increased risk for infection.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident with Huntington's Disease and other conditions did not consistently receive the prescribed dietary supplement, Boost, with meals, as per physician orders. Observations and interviews revealed that the supplement was missing from the resident's meal tray on multiple occasions, despite the facility's protocol to ensure dietary orders are followed. The responsibility for providing the supplement was confirmed to lie with the nursing staff, but lapses in adherence to the orders were noted.
The facility did not follow its policy to date multidose vials upon opening, as observed in two medication refrigerators. Opened vials of Novolin R and Levemir were found undated, despite staff training on this procedure. Interviews with nursing staff and the DON confirmed the responsibility to date vials, highlighting a lapse in adherence to the policy.
A facility failed to ensure a CNA followed a resident's care plan, resulting in an unwitnessed fall. The resident, with profound IDD and other conditions, required siderails while in bed. Despite this, the CNA lowered the siderails to prevent agitation, leading to the fall. The incident was confirmed by the Administrator, DON, and the CNA involved, all acknowledging the care plan was not followed.
A resident with severe cognitive impairment and multiple diagnoses fell from bed because the assigned CNA did not follow the physician's order to keep the side rails up. The CNA lowered the side rails to prevent agitation but did not inform the nurse on duty, leading to the resident's fall. The facility's investigation confirmed that the CNA was aware of the side rail requirement but chose not to follow it.
Late Meal Service and Extended Overnight Interval
Penalty
Summary
The facility failed to ensure meals were served at regular intervals that did not exceed 14 hours between the evening meal and the morning meal, or 16 hours when a bedtime snack is provided, for residents in building #31. On 10/09/2025 at 10:05 AM, an observation showed residents in building #31 eating breakfast. During an interview at 10:28 AM, the Director of Operations stated breakfast was served at 9:45 AM, which was two hours later than the scheduled time for residents in building #31. During interviews, the Director of Operations stated snacks are served at 10 AM and 2 PM daily and are given at night for diabetic residents, while non-diabetic residents have access to snacks if they ask. She confirmed that if a non-diabetic resident did not ask for a snack on Wednesday night, the resident would have gone almost 17 hours without a meal until breakfast Thursday morning. The Food Service Aide stated dinner was delivered to the building at 4:30 PM and served to residents at 4:55 PM on 10/8/25, while the meal schedule record listed dinner at 5:15 PM and breakfast at 7:45 AM. The Nursing Home Administrator also confirmed awareness that meals were being delivered late and stated her expectation was that food be served on time, hot, and appealing.
Improper Glove Use During Food Temperature Checks
Penalty
Summary
The facility failed to ensure that food was prepared and served in a sanitary manner to prevent foodborne illness. During breakfast temperature checks in the dietary department, a Dietary Member #2 opened the kitchen door while wearing gloves and then returned to taking food temperatures without removing the gloves, washing her hands, or putting on new gloves before resuming food handling. The facility’s Food Storage policy and Food Preparation and Meal Service policy both required employees to maintain good personal hygiene and safe food-handling practices during food storage, preparation, and service. During interview, the dietary staff member acknowledged that she should have removed her gloves, performed hand hygiene, and applied new gloves after touching the door handle, and stated that proper hand hygiene is important to prevent the spread of germs and maintain food safety.
Care Plan Did Not Address Dialysis Weight Monitoring
Penalty
Summary
The facility failed to implement the resident's care plan for monitoring dialysis weights and identifying changes in condition for one resident with End-Stage Renal Disease. The facility policy stated that a comprehensive, person-centered care plan would be developed and implemented by the interdisciplinary team, resident, and legal representative, with measurable objectives and timetables to meet the resident's needs. However, the Care Plan Report initiated on 7/30/2025 listed the focus as at risk for altered nutritional status related to CKD/ESRD and included an intervention to notify the MD, RD, and correspondent of significant weight changes. There was no individualized care plan intervention addressing the resident's ongoing need for dialysis, no direction to monitor pre- and post-dialysis weights, no instruction to communicate with the dialysis clinic, and no plan to evaluate trends in fluid balance despite the ESRD diagnosis. During interview, the RN who served as the Care Plan Nurse stated that the care plan should provide a clear baseline of care so any nurse could know exactly what the resident needs are, and that dialysis weights are significant because they inform staff of changes in the resident before and after dialysis. The resident's identification and summary sheet showed admission to the facility with diagnoses including ESRD.
Incomplete Dialysis Communication Forms
Penalty
Summary
The facility failed to ensure completion and follow-up of dialysis communication forms used to coordinate care for a resident receiving routine hemodialysis. Resident #9 was admitted with End-Stage Renal Disease (ESRD) and had a BIMS score of 15, indicating intact cognition. Review of the Dialysis Communication Form showed missing pre- and post-dialysis weights for August 6, 8, 11, and 18, 2025. The facility policy stated that when a resident needs hemodialysis, the contracted dialysis entity will arrange, develop, implement, and exchange information with the facility regarding the resident’s dialysis care plan. During interview, RN #2 stated dialysis nurses were responsible for completing the weights on the communication form and acknowledged that when forms were returned incomplete, facility staff assumed there were no issues requiring follow-up and did not request the missing information. The Dialysis Manager at the local dialysis center stated that if forms are missing or incomplete, it is standard practice for the facility to call the dialysis center and request the missing information via fax or email, and she had no knowledge of any request made by facility staff for the missing data. The DON stated this was the facility’s first dialysis resident and described the situation as a learning opportunity, stating staff lacked training in monitoring dialysis residents.
Missing Dialysis Weight Documentation
Penalty
Summary
The facility failed to ensure the provision of physician-ordered care and services for a resident receiving dialysis by not accurately corresponding, obtaining, and documenting dialysis weights. Resident #9 was admitted with End-Stage Renal Disease requiring routine dialysis, and the MDS indicated intact cognition with a BIMS score of 15. Review of the resident’s dialysis communication forms showed that no pre- or post-dialysis weights were documented for August 6, 8, 11, and 18, 2025, despite physician orders for dialysis three times per week, a renal-high diet, weekly and as-needed vital signs, and monthly and as-needed weights. During interviews, RN #3 stated nursing staff had never completed pre- and post-dialysis weights for residents receiving dialysis and that dialysis-clinic nurses were responsible for documenting weights in the dialysis unit records and on the communication forms, while facility nursing staff were expected to obtain dialysis weights. RN #2 stated dialysis-clinic staff completed the weights and acknowledged that when forms were returned without weight information, facility nurses assumed there were no concerns and did not contact the dialysis clinic to obtain the missing information. The DON stated the facility maintained dialysis communication through written, verbal, or electronic means, that dialysis information including weights was used by the interdisciplinary team, and that staff had not been trained on monitoring dialysis residents and completing related documentation. RN #1 stated dialysis weights are critical indicators for assessing changes in the resident’s condition before and after dialysis.
Incomplete Dialysis Weight Documentation
Penalty
Summary
The facility failed to ensure accurate and complete documentation of dialysis weights for Resident #9, a resident with End-Stage Renal Disease receiving routine hemodialysis. Record review showed that pre- and post-dialysis weights were not documented on the dialysis communication form for four treatment days in August 2025, specifically August 6, 8, 11, and 18. The resident’s record also showed a BIMS score of 15, indicating intact cognition, and physician orders for dialysis three times per week, a renal-high diet, weekly and as-needed vital signs, and monthly and as-needed weights. Interviews showed that nursing staff and dialysis-clinic staff both expected dialysis weights to be documented, but the facility did not obtain the missing information when the forms were returned incomplete. RN #3 stated facility nursing staff had never completed pre- and post-dialysis weights for residents receiving dialysis, while RN #2 stated that when the dialysis communication forms came back without weight information, staff assumed there were no concerns and did not contact the dialysis clinic. The dialysis manager and dialysis center social worker confirmed that weights are recorded by dialysis staff and that facility staff can contact the dialysis center for missing information, but they had no knowledge of any requests from the facility for the missing documentation. The DON stated the facility was the resident’s first dialysis case and that staff lacked training on monitoring dialysis residents and completing related documentation.
Failure to Use EBP During Wound Care
Penalty
Summary
The facility failed to prevent the possible spread of infection during wound care by not implementing Enhanced Barrier Precautions (EBP) for one resident with bilateral lower leg wounds. During an initial tour on 10/06/2025, an LPN was observed providing bilateral wound care to Resident #11 without wearing a gown, even though the resident had open areas requiring dressing and the facility’s EBP signage and policy required gloves and a gown for wound care. The LPN later confirmed she did not have a gown on while doing the wound care and stated she knew she was supposed to wear one, but had not looked at the EBP signage and forgot to put it on. She stated the gown was intended to protect residents from infection from the outside and acknowledged her actions put the resident at risk for infection. The DON stated the LPN should have worn a gown and that staff are expected to follow the posted EBP signage and facility policy. The IP nurse also stated staff should wear gowns and gloves during care and that not wearing a gown increased the risk of infection spread. Resident #11 had diagnoses including peripheral vascular disease, an order for daily wound care to both lower legs, and a BIMS score of 15 indicating cognitive intactness.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Provide Prescribed Dietary Supplements
Penalty
Summary
The facility failed to follow physician orders for dietary supplements for a resident, leading to a deficiency in nutritional care. Observations revealed that the resident, who could feed himself, did not receive the prescribed dietary supplement, Boost, with his meals on multiple occasions. On one occasion, a CNA noticed the absence of Boost and retrieved it for the resident, who then consumed it immediately. Interviews with the Registered Dietitian (RD) and CNAs confirmed that the resident was supposed to receive Boost four times a day, as per the physician's orders. However, the supplement was not consistently provided with the resident's meals. The Director of Nursing (DON) stated that when there is a nutritional change, the order is communicated to relevant staff, including the RD, pantry personnel, nurses, and CNAs. It was confirmed that it is the nurse's responsibility to ensure the resident receives the supplement as ordered and to document it accurately. Despite this protocol, the resident's dietary supplement was not consistently provided, indicating a lapse in following the physician's orders. The resident's medical history includes Huntington's Disease, Depression, and Gastric Esophageal Reflux Disease, and the physician's orders specified a pureed diet with double portions and Boost four times a day.
Failure to Date Opened Multidose Vials
Penalty
Summary
The facility failed to adhere to its policy regarding the dating of multidose vials upon opening, as observed in two of the four medication refrigerators in the medication storage rooms. During an inspection, it was found that vials of Novolin R and Levemir in the medication refrigerators on both the first and second floors of Building 33 were opened but not dated. This is contrary to the facility's policy, which requires that all multidose vials be dated with a 28-day expiration date from the time of initial puncture. Interviews with nursing staff, including an LPN and an RN, revealed that it was the responsibility of the nurse who opened the vial to date it. Both nurses confirmed that they had received training on medication labeling and storage, including the importance of dating insulin vials. The Director of Nursing also confirmed that nurses were trained on this policy and were expected to follow it. Despite this training, the failure to date the vials was observed, indicating a lapse in adherence to the established procedures.
Failure to Follow Care Plan Results in Resident Fall
Penalty
Summary
The facility failed to ensure a Certified Nurse Aide (CNA) followed the resident's care plan, resulting in an unwitnessed fall from the bed for one of the residents reviewed for accidents. The care plan for the resident, who has profound Intellectual and Developmental Disability (IDD), Delusional Disorder, and is unaware of safety hazards, required the use of siderails while in bed. Despite this, CNA #1 decided to lower the siderails to prevent the resident from becoming agitated, which led to the resident falling from the bed. The incident was confirmed by the Administrator, Director of Nursing (DON), and the CNA involved, all of whom acknowledged that the care plan was not followed as required. The resident, admitted to the facility with diagnoses including Delusional Disorder, Atrial Fibrillation, and Hypertension, fell from the bed when the siderails were not in place as specified in the care plan. The Licensed Practical Nurse (LPN) who assessed the resident after the fall confirmed that the siderails were down at the time of the incident. The DON stated that CNAs had been educated on following the care plan, and the ADL guidebook, which includes specific care instructions for each resident, reflected the siderail requirement for this resident. However, CNA #1 did not adhere to these guidelines, leading to the fall.
Failure to Implement Physician-Ordered Assistive Devices
Penalty
Summary
The facility failed to ensure a dependent resident was supervised and that physician-ordered assistive devices were implemented to prevent an unwitnessed fall from bed. The resident, who had severe cognitive impairment and diagnoses including Delusional Disorder, Atrial Fibrillation, and Hypertension, had a physician's order for the bed's side rails to be up due to her inability to foresee potential hazards. However, the assigned CNA did not follow this order and lowered the side rails, leading to the resident's fall. The CNA admitted to not notifying the nurse on duty about the resident's behaviors or the decision to lower the side rails. The facility's investigation revealed that the CNA was aware of the side rail requirement as documented in the ADL guidebook but chose to lower the rails to prevent the resident from becoming agitated. The CNA's actions were not communicated to the nurse on duty, who later found the resident on the floor with the side rails down. The facility's policy and the resident's care plan were not adhered to, resulting in the fall. Interviews with the Administrator and DON confirmed that staff are expected to follow physician orders and the care plan, which was not done in this case.
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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 Whitfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jnh-jaquith Inn | 0 mi | ★★★★★ | 7 | 0 |
| Jnh-madison Inn | 0 mi | ★★★★★ | 2 | 0 |
| Wisteria Gardens | 3.5 mi | ★★★★★ | 3 | 0 |
| Brandon Community Care Center | 4.1 mi | ★★★★★ | 2 | 0 |
| Brandon Court | 4.3 mi | ★★★★★ | 1 | 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.