Inspection Reports for Jackson Creek Post Acute
3980 SOUTH JACKSON DR, INDEPENDENCE, MO, 64057-2205
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
99 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Routine
Census: 99
Deficiencies: 4
Date: Apr 10, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, dialysis care, infection control, and communication between the facility and dialysis provider for a nursing home with 99 residents.
Findings
The facility failed to notify a resident's physician about medication refusals and late insulin administration, failed to document and communicate medication refusals properly, lacked a policy addressing sliding scale insulin, failed to ensure communication with the dialysis provider, and failed to follow infection control protocols during central venous catheter dressing changes.
Deficiencies (4)
Failed to notify resident's physician of refusal of dialysis medication and late insulin administration.
Failed to document and communicate medication refusals and omissions correctly and failed to revise care plan to address medication refusal.
Failed to ensure communication between facility and dialysis provider for coordinated care.
Failed to ensure infection control measures during central venous catheter dressing change, including failure to cleanse site, use mask and gown, and use barrier.
Report Facts
Residents affected: 7
Facility census: 99
Medication dosage: 12
Medication dosage: 800
Dialysis schedule: 4
Central line dressing change frequency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Named in medication refusal and documentation findings |
| Agency Registered Nurse A | Agency Registered Nurse | Named in findings related to missed blood glucose monitoring and insulin administration |
| Nurse Unit Manager A | Nurse Unit Manager | Named in findings related to notification failures and medication documentation |
| Director of Nursing | Director of Nursing | Named in findings related to oversight of medication administration and infection control |
| Licensed Practical Nurse B | Licensed Practical Nurse | Named in findings related to lack of communication with dialysis provider |
| Nurse Manager B | Nurse Manager | Named in infection control and central line dressing findings |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 4
Date: Oct 31, 2024
Visit Reason
The inspection was conducted due to a complaint regarding failure to ensure a resident received physician-ordered dialysis services on 10/22/24 and 10/24/24, and failure to notify appropriate parties of missed dialysis, a fall, and changes in condition.
Complaint Details
The complaint investigation revealed that the resident missed dialysis on 10/22/24 and 10/24/24 due to transportation failures and lack of staff notification. The resident had a fall on 10/25/24, which was also not promptly reported. The resident was hospitalized on 10/26/24 with serious complications related to missed dialysis. The facility was not aware or did not notify key personnel including the physician, family, and administration in a timely manner. Immediate jeopardy was identified but removed after corrective actions.
Findings
The facility failed to ensure nursing staff notified the resident's physician, family, and department heads about missed dialysis sessions and a fall. The resident missed dialysis on two occasions, resulting in hospitalization for serious complications. The facility also failed to arrange transportation for dialysis and notify responsible parties in a timely manner. Interviews confirmed multiple staff and administrators were unaware or failed to act on the missed dialysis and fall notifications.
Deficiencies (4)
Failure to ensure nursing staff notified the next of kin, physician, and department heads when the resident missed dialysis on 10/22/24 and 10/24/24, had increased blood pressure, and had a fall on 10/25/24.
Failure to provide safe, appropriate dialysis care/services for a resident who required such services, resulting in immediate jeopardy that was later removed.
Failure to ensure transportation was arranged for dialysis after resident readmission, contributing to missed dialysis treatments and subsequent hospitalization.
Failure to notify physician, family, and administrative staff timely about missed dialysis and resident fall.
Report Facts
Facility census: 91
Missed dialysis dates: 2
Dialysis schedule: 3
Dialysis pick-up time: 545
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Nurse responsible on 10/22/24 and 10/24/24 who failed to notify about missed dialysis and resident condition |
| LPN B | Licensed Practical Nurse | Charge nurse on 10/26/24 who arranged transportation and notified administration about missed dialysis |
| Unit Manager | Signed resident transfer to hospital and provided interview about notification expectations | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding notification failures and dialysis transportation issues |
| Administrator | Facility Administrator | Interviewed regarding lack of awareness of missed dialysis and fall |
| Medical Director | Medical Director | Notified late about missed dialysis and resident fall; provided clinical perspective |
| Admissions Director | Admissions Director | Responsible for setting up dialysis transportation but unaware of responsibility until after incident |
| Family Member A | Family member not notified of missed dialysis or fall until late | |
| Dialysis Center Staff A | Reported communication with facility about missed dialysis and resident condition at dialysis center | |
| Nurse Practitioner | Nurse Practitioner | Interviewed about expectations for dialysis and notification |
| Certified Nursing Aide (CNA) A | Certified Nursing Aide | Notified nurse of resident fall on 10/25/24 |
| LPN C | Licensed Practical Nurse | On-call nurse who was informed about missed dialysis on 10/24/24 but did not follow up |
| LPN D | Licensed Practical Nurse | Interviewed about notification expectations |
| Social Services Designee | Would have assisted with transportation if notified | |
| Hospital Registered Nurse (RN) A | Registered Nurse | Provided hospital care and described resident condition on admission |
Inspection Report
Routine
Census: 105
Deficiencies: 3
Date: May 7, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to PASARR screening for mental disorders, fall prevention interventions, and safe transfer practices in a nursing home setting.
Findings
The facility failed to ensure timely completion of PASARR Level I screening for a resident with major mental illness, failed to implement adequate fall prevention interventions and supervision for residents with a history of falls, and failed to ensure staff used gait belts during resident transfers as required.
Deficiencies (3)
Failed to ensure a resident with a major mental illness diagnosis had a required DA-124C/Level I PASARR screening in a timely manner.
Failed to ensure adequate fall prevention interventions were added to a care plan in a timely manner and implemented for a resident with a history of falls.
Failed to ensure staff utilized a gait belt for a resident requiring assistance with transfers.
Report Facts
Residents sampled: 21
Facility census: 105
Fall incident dates: 2
Fall follow-up duration: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker A | Responsible for ensuring DA-124C completion; interviewed regarding PASARR screening | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding PASARR requirements, fall investigations, and care plan interventions |
| Licensed Practical Nurse C | Licensed Practical Nurse (LPN) | Interviewed regarding fall interventions and care plan |
| Certified Nursing Assistant F | Certified Nursing Assistant (CNA) | Observed transferring resident without gait belt; interviewed about transfer procedures |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed about gait belt use during transfers |
| Certified Nursing Assistant C | Certified Nursing Assistant (CNA) | Interviewed about gait belt use and fall interventions |
| Director of Therapy | Interviewed about transfer assistance and gait belt use | |
| Registered Nurse A | Registered Nurse (RN) | Interviewed about proper transfer procedures and gait belt use |
| Unit Manager | Responsible for fall investigations and care plan interventions |
Inspection Report
Routine
Census: 105
Deficiencies: 12
Date: May 7, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements for nursing home care, including resident safety, care quality, and facility conditions.
Findings
The facility was found deficient in multiple areas including maintenance of assistive devices, timely PASARR screening, medication self-administration assessments, activity programming, fall prevention interventions, dialysis care, trauma-informed care planning, bed rail safety, food temperature and palatability, food storage labeling, and infection control practices during blood glucose monitoring and insulin administration.
Deficiencies (12)
Failed to maintain commode risers and mechanical lifts in sound and cleanable condition, potentially affecting 12 residents.
Failed to ensure timely PASARR Level I screening for a resident with major mental illness diagnosis.
Failed to assess residents for safety of self-administration of OTC medications and failed to observe medication administration for one resident.
Failed to provide ongoing activity program based on comprehensive assessment and care plan of residents' interests and abilities for two residents.
Failed to ensure adequate fall prevention interventions were added and implemented timely for a resident with history of falls and failed to ensure use of gait belt during transfers for another resident.
Failed to provide ongoing assessments and accurate documentation of dialysis site for a resident requiring dialysis.
Failed to ensure comprehensive PTSD care plan and staff education on triggers and interventions for a resident with PTSD.
Failed to consider all appropriate alternatives prior to installing bed rails and failed to ensure bed rails were compatible with bed and safely installed for a resident with history of falls.
Failed to make pureed eggs palatable and maintain hot foods on room trays at safe temperatures during breakfast meal, potentially affecting at least six residents.
Failed to remove grime and debris from kitchen equipment, ensure dietary aide's hair was fully covered, label unknown substances and maintain milk at safe temperature in resident use refrigerator, potentially affecting all residents.
Failed to ensure food in resident use refrigerator was labeled with resident's name and date brought in, contrary to facility policy, potentially affecting an unknown number of residents.
Failed to ensure hand hygiene, use of barriers, and proper sanitization of glucometer during blood glucose monitoring and insulin administration for three residents.
Report Facts
Facility census: 105
Residents affected: 12
Residents affected: 6
Room tray temperature: 115.7
Room tray temperature: 115
Room tray temperature: 95.9
Milk temperature: 48.3
Bed rail spacing: 0.75
Bed rail spacing: 7.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Named in infection control deficiency during blood glucose monitoring and insulin administration |
| CNA A | Certified Nursing Assistant | Mentioned in observation of medication left at bedside and resident care |
| LPN C | Licensed Practical Nurse | Mentioned in medication self-administration and fall prevention interviews |
| DON | Director of Nursing | Mentioned in multiple interviews regarding care plans, fall prevention, bed rails, dialysis care, and infection control |
| Maintenance Supervisor | Responsible for bed rail installation and maintenance | |
| Dietary Manager | Mentioned in food preparation and temperature control deficiencies | |
| Consultant Registered Dietitian | Mentioned in food preparation and temperature control interviews | |
| Activities Director | Mentioned in activity programming deficiencies and interviews |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Date: Jun 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident injury that occurred during a transfer using a sit-to-stand lift.
Complaint Details
Complaint # MO00219627. The complaint involved a resident who sustained a traumatic wound to the right lower leg during a transfer. The injury was investigated and substantiated as the result of a one-person sit-to-stand transfer by an Agency CNA instead of the required two-person assist.
Findings
The facility failed to safely provide a two-person assist sit-to-stand lift transfer for one resident, resulting in a major injury with a deep tissue laceration to the resident's right lower leg. The investigation found that an Agency CNA performed a one-person transfer contrary to facility policy requiring two-person assistance, leading to the injury. The facility provided education and updated policies to ensure two-person transfers for mechanical lifts.
Deficiencies (1)
Failure to safely provide a two person assist sit-to-stand lift transfer resulting in a major injury to a resident.
Report Facts
Facility census: 101
Resident injury date: Jun 3, 2023
Report date: Jun 14, 2023
Wound dressing size: 9
Pain rating: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency CNA A | Certified Nursing Assistant | Named in the finding for performing a one-person sit-to-stand transfer that caused resident injury |
| CNA B | Certified Nursing Assistant | Interviewed regarding resident transfer and injury |
| Director of Rehabilitation Services | Director of Rehabilitation Services | Interviewed about resident transfer and injury investigation |
| Registered Nurse B | Registered Nurse | Interviewed about resident injury and transfer procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding investigation findings and staff education |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 31, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction report for Jackson Creek Post Acute following a survey completed on 2023-05-31.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Census: 98
Capacity: 120
Deficiencies: 7
Date: Aug 10, 2022
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with professional standards of quality, medication management, fall prevention, pharmacy medication regimen reviews, drug regimen appropriateness, infection control, and food safety in the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to provide ordered eye drops, inadequate fall documentation and follow-up, incomplete monthly pharmacy medication regimen reviews and physician responses, lack of diagnoses for medications, failure to limit PRN psychotropic medication orders to 14 days, inadequate infection prevention practices including missing tuberculosis testing for some residents, and multiple food safety violations such as unclean floors, pest infestation, damaged utensils, uncovered food, and improper food temperature documentation.
Deficiencies (7)
Failed to provide eye drops as ordered for one resident due to unavailability from 7/28/22 to 8/4/22.
Failed to follow fall policy including documentation of unwitnessed fall, fall investigation, and 72-hour post-fall documentation for one resident.
Failed to provide monthly pharmacy medication regimen reviews for two residents and failed to provide physician responses to pharmacist recommendations for two residents.
Failed to ensure each resident's drug regimen had diagnoses or adequate indications for medications for five residents and one supplemental resident.
Failed to ensure PRN anti-anxiety medication order had a 14-day limit for one resident.
Failed to maintain infection prevention and control program by not providing tuberculosis testing for two residents.
Failed to maintain kitchen, dry storage, walk-in refrigerator and freezer floors clean and free from pests; failed to safeguard against foreign material in food; failed to keep trash receptacles lidded; failed to document food temperatures; failed to maintain cutting boards and utensils in good condition; and failed to separate damaged foodstuff.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 5
Residents affected: 1
Residents affected: 2
Facility census: 98
Facility capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Interviewed regarding missing eye drops and pharmacy delivery |
| Agency Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding medication availability and fall documentation |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration, fall policy, pharmacy reviews, PRN medication limits, and TB testing |
| Administrator | Administrator | Interviewed regarding pharmacy recommendations, TB testing, and pest control |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding kitchen cleaning, food safety, and pest control |
| Maintenance Director | Maintenance Director | Interviewed regarding pest control |
| Pharmacist | Consulting Pharmacist | Interviewed regarding medication regimen reviews and diagnoses for medications |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding PRN medication limits and TB testing |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 6
Date: Nov 5, 2019
Visit Reason
The inspection was conducted due to complaints regarding coordination of dialysis care, narcotic count procedures, medication regimen reviews, medication storage, infection prevention and control practices, and proper use of isolation equipment.
Complaint Details
The visit was complaint-related, triggered by concerns about dialysis care coordination, narcotic count compliance, medication regimen review irregularities, medication storage issues, and infection control practices including hand hygiene and equipment sanitation.
Findings
The facility failed to ensure proper coordination of dialysis care communication, consistent narcotic counts with signatures, pharmacist review of PRN psychotropic medication orders with appropriate duration, proper medication storage with open dates and removal of expired medications, adherence to infection control practices including hand hygiene and glove changes during resident care, and proper cleaning/disinfection of community equipment used in isolation.
Deficiencies (6)
Failed to ensure coordination of care between the facility and dialysis center for one resident, including incomplete dialysis communication worksheets.
Failed to ensure narcotic counts were done every shift with signatures from on-coming and off-going staff, with high rates of missing signatures.
Failed to ensure pharmacy consultant identified irregularities in PRN psychotropic medication orders, including lack of duration limits and clinical indication for extended use.
Failed to implement gradual dose reductions and limit PRN psychotropic medication orders to 14 days with clinical indication for extensions.
Failed to ensure open dates on opened multi-dose medications, removal of expired medications, proper storage, and cleanliness of medication carts.
Failed to complete appropriate hand washing and glove changing during perineal care, catheter care, medication pass, and failed to properly clean/sanitize community equipment used for residents on isolation.
Report Facts
Facility census: 104
Sampled residents: 21
Narcotic count missing signatures September 2019: 25
Narcotic count missing signatures October 2019: 75
PRN alprazolam order date: 2018
Last PRN alprazolam administration: 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse F | Licensed Practical Nurse | Described dialysis communication worksheet process and noted forms were not completed for resident |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding dialysis communication, narcotic counts, medication regimen reviews, infection control expectations |
| Certified Medication Technician D | Certified Medication Technician | Described narcotic count procedures |
| Licensed Practical Nurse D | Licensed Practical Nurse | Described narcotic count procedures |
| Licensed Practical Nurse E | Licensed Practical Nurse | Described narcotic count expectations |
| Licensed Practical Nurse G | Licensed Practical Nurse | Discussed PRN alprazolam order and medication administration |
| Certified Nursing Assistant D | Certified Nursing Assistant | Observed and interviewed regarding peri-care glove use and hand hygiene |
| Certified Nursing Assistant E | Certified Nursing Assistant | Observed and interviewed regarding peri-care glove use and hand hygiene |
| Licensed Practical Nurse C | Licensed Practical Nurse | Discussed hand hygiene during medication pass and use of community thermometer |
| Certified Medication Technician C | Certified Medication Technician | Observed during medication pass with poor hand hygiene and improper use of community thermometer |
| 400 Unit Manager | Unit Manager | Provided interview on medication cart expectations and infection control |
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