Inspection Reports for
Jackson Creek Post Acute
3980 SOUTH JACKSON DR, INDEPENDENCE, MO, 64057-2205
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
12.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
129% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
23% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 41
Deficiencies: 10
Date: Jun 12, 2025
Visit Reason
The document is a Plan of Correction submitted following a state survey inspection conducted on 06/12/2025 at Jackson Creek Post Acute to address identified deficiencies.
Findings
The facility was cited for multiple deficiencies including failure to maintain fire safety in exterior premises, improper hot water temperature control, failure to obtain and display an elevator operating certificate, incomplete individualized service plans, improper medication storage and handling, failure to ensure safe insulin administration, incomplete resident condition and medication reviews, and failure to maintain clean floor surfaces and dumpster areas. The facility census was consistently reported as 41 residents.
Deficiencies (10)
19 CSR 30-86.022(2)(F) Exterior Premises-Fire Safety. The facility failed to maintain outdoor areas for fire safety, including presence of sandbags outside exit doors and slippery exit discharge areas.
19 CSR 30-86.032(34) Hot Water 105-120 Degrees F. The facility failed to maintain hot water temperatures within the required range at multiple resident room faucets, affecting 16 residents.
19 CSR 30-86.047(6) Operator/Administrator Responsibilities. The facility failed to obtain and display the elevator operating certificate as required by state regulation.
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop. The facility failed to ensure an individualized service plan was updated for one sampled resident out of four reviewed.
19 CSR 30-86.047(41)(C) Medication Storage-Separate, Not In Use. The facility failed to ensure medications were properly stored and destroyed after expiration, with expired medications found in the medication cart and pharmacy room.
19 CSR 30-86.047(46) Safe & Effective Medication System. The facility failed to maintain a safe medication system, including expired medication handling and staff responsibilities.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review. The facility failed to maintain monthly summaries of residents' general condition and medication reviews for four sampled residents.
19 CSR 30-87.020(12) Floor Surfaces. The facility failed to maintain clean floors in food preparation and walk-in refrigerator areas, with food debris and grime observed.
19 CSR 30-87.020(32) Outside Dumpsters Cleanable/Covered. The facility failed to keep the outdoor dumpster lid closed and remove scattered debris around the dumpster.
19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily. The facility failed to clean the bread toaster regularly, resulting in heavy buildup of crumbs.
Report Facts
Facility census: 41
Residents affected by hot water temperature deficiency: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication storage, insulin administration, and resident care plans |
| Maintenance Director | Maintenance Director | Interviewed regarding exterior premises fire safety and drainage issues |
| Level One Medication Aide B | Level One Medication Aide (L1MA) B | Interviewed regarding expired medication handling |
| Level One Medication Aide A | Level One Medication Aide (L1MA) A | Observed administering insulin and interviewed about insulin pen use |
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
Plan of Correction
Census: 99
Deficiencies: 7
Date: Apr 10, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident care, medication administration, infection control, dialysis communication, and notification of changes in resident condition at Jackson Creek Post Acute.
Findings
The facility was found deficient in notifying physicians of resident condition changes, documenting medication refusals and administration, ensuring communication with dialysis providers, and maintaining infection prevention protocols. Several policies and procedures were not followed or adequately documented, affecting one sampled resident and potentially others.
Deficiencies (7)
F580 Notification of Changes. The facility failed to notify the physician of a resident's refusal of dialysis medication and late administration of sliding scale insulin. The facility census was 99 residents.
F684 Quality of Care. The facility failed to ensure proper documentation and communication of medication refusals and late administration of sliding scale insulin for one sampled resident. The facility census was 99 residents.
F698 Dialysis. The facility failed to ensure communication between the facility and dialysis provider for one sampled resident with end stage renal disease. The facility census was 99 residents.
F880 Infection Prevention & Control. The facility failed to establish and maintain an infection prevention program including proper central line dressing changes and use of enhanced barrier precautions for one sampled resident. The facility census was 99 residents.
A4075 Nursing Care per Resident Condition. The facility failed to provide personal attention and nursing care consistent with resident condition as evidenced by deficiencies in F580, F684, F698, and F880.
A4086 Infection Control/Communicable Disease. The facility failed to implement infection control procedures to prevent spread of infection as evidenced by deficiency F880.
A4087 Dr Notification-Change in Condition. The facility failed to notify the resident's physician in the event of significant change in condition as evidenced by deficiency F580.
Report Facts
Facility census: 99
Sampled residents: 7
Completion date for plan of correction: May 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in interviews regarding medication administration and dialysis communication deficiencies |
| Nurse Unit Manager A | Nurse Unit Manager | Interviewed regarding medication administration and notification procedures |
| Agency Registered Nurse A | Registered Nurse (RN) | Interviewed about resident's lunch time blood glucose monitoring and medication administration |
| Certified Medication Technician A | Certified Medication Technician (CMT) | Interviewed about resident medication refusals and documentation |
| Licensed Practical Nurse (LPN) B | Licensed Practical Nurse | Interviewed about dialysis communication and documentation |
| Nurse Manager B | Nurse Manager | Interviewed about central line dressing kit supplies and infection control |
| Infection Preventionist | Infection Preventionist | Responsible for in-service education and infection control audits |
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
Complaint Investigation
Census: 91
Deficiencies: 6
Date: Oct 31, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify appropriate parties about a resident's missed dialysis and fall incidents.
Complaint Details
The complaint investigation found that the facility failed to notify the resident, family, physician, and department heads about missed dialysis on 10/22/24 and 10/24/24 and a resident fall on 10/25/24. The resident was hospitalized on 10/26/24 due to complications including elevated potassium and low hemoglobin. Interviews with staff and family confirmed lack of notification and communication.
Findings
The facility failed to notify the resident, family, physician, and department heads about missed dialysis appointments and a resident fall. The resident was hospitalized due to complications related to missed dialysis and lack of timely communication.
Deficiencies (6)
F580 Notification of Changes. The facility failed to ensure nursing staff notified the next of kin, physician, and department heads when a resident missed dialysis and had a fall, resulting in hospitalization.
F698 Dialysis. The facility failed to ensure a resident requiring dialysis received ordered dialysis services and timely notification of condition changes, resulting in hospitalization.
A4075 Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with their condition. This was not met as referenced in F698.
A4087 Doctor Notification-Change in Condition. Facility staff failed to notify the resident's physician of significant changes in condition as required, referenced in F580.
A4088 Notify Responsible Party-Change in Condition. Facility staff failed to notify the resident's designated responsible party of significant condition changes, referenced in F580.
A4089 Inform Administrator of Accidents. Staff failed to inform the administrator of accidents and unusual occurrences affecting the resident, referenced in F580.
Report Facts
Facility census: 91
Dates of missed dialysis: Missed dialysis on 10/22/24 and 10/24/24
Date of resident fall: Resident fall on 10/25/24
Date of hospitalization: Resident hospitalized on 10/26/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Signed nurse notes related to dialysis and missed dialysis documentation |
| LPN B | Licensed Practical Nurse | Advised resident needed to come to dialysis or hospital; involved in communication failures |
| LPN C | Licensed Practical Nurse | On-call nurse during 10/21/24-10/27/24; involved in notification about missed dialysis |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding notification failures and resident care |
| Administrator | Facility Administrator | Interviewed regarding awareness of missed dialysis and resident fall |
| Medical Director | Medical Director | Interviewed regarding notification of missed dialysis and resident fall |
| Unit Manager | Unit Manager | Interviewed regarding resident transport and notification failures |
| Family Member A | Interviewed regarding lack of notification about missed dialysis and fall | |
| Hospital Registered Nurse | RN | Provided information on resident admission and condition |
| Certified Nurse Aide | CNA | Reported resident fall to nurse |
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
Census: 101
Deficiencies: 1
Date: Jun 14, 2023
Visit Reason
The inspection was conducted to investigate and address a deficiency related to accident hazards and supervision/devices following an incident involving a resident injury during transfer.
Complaint Details
Complaint # MO00219627 was investigated related to the resident injury during transfer. The complaint was substantiated as the facility failed to provide proper two-person assist as required.
Findings
The facility failed to safely provide a two-person assist sit-to-stand lift, resulting in a major injury to a resident's right lower leg. The deficiency was corrected as of 06/06/2023 with staff education and updated procedures.
Deficiencies (1)
F 689: The facility did not ensure the resident environment remained free of accident hazards and failed to provide adequate supervision and assistance devices, resulting in a major injury to a resident during transfer with a sit-to-stand lift. The deficiency was corrected by 06/06/2023 with staff education and updated policies.
Report Facts
Facility census: 101
Resident pain rating: 10
Wound dressing size: 9
Date of injury: Jun 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency Certified Nursing Assistant A | CNA | Named in injury incident and investigation for improper transfer |
| Administrator | Administrator | Notified of past noncompliance and involved in investigation |
| Restorative Aide | Restorative Aide | Interviewed regarding resident transfer and injury |
| Director of Rehabilitation Services | Director of Rehabilitation Services | Interviewed about resident's therapy and transfer status |
| Registered Nurse B | Registered Nurse | Interviewed regarding resident's wound and transfer |
| Wound Nurse | Wound Nurse | Interviewed regarding resident's wound and transfer |
| Director of Nursing | Director of Nursing | Interviewed about 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
Routine
Deficiencies: 0
Date: May 31, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 2
Date: Jan 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged resident-to-resident abuse involving two sampled residents.
Complaint Details
The complaint investigation substantiated that Resident #1 and Resident #2 were involved in a physical altercation causing injury to Resident #1. The facility failed to prevent the abuse despite multiple staff observations and resident statements confirming the incident.
Findings
The facility failed to prevent resident abuse resulting in skin tears to one resident's left forearm during a verbal and physical altercation between two residents. Multiple interviews and record reviews confirmed the incident and the facility's inadequate prevention measures.
Deficiencies (2)
F600 Freedom from Abuse and Neglect: The facility failed to prevent resident abuse for two sampled residents involved in a verbal and physical altercation resulting in skin tears to one resident's left forearm.
A8023 Develop/Implement Abuse/Neglect Policies: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents as required by regulation.
Report Facts
Facility census: 94
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
Plan of Correction
Census: 98
Capacity: 120
Deficiencies: 7
Date: Aug 10, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Villages of Jackson Creek SNF following a survey conducted on 08/10/2022. The purpose is to report deficiencies found during the inspection and the facility's plan to correct them.
Findings
The facility was found deficient in multiple areas including failure to meet professional standards in comprehensive care plans, failure to follow fall policies, failure to provide timely pharmacy medication regimen reviews, infection control deficiencies, and food safety violations. The census was 98 residents with a licensed capacity of 120 beds.
Deficiencies (7)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) The facility failed to provide ordered eye drops for one sampled resident, violating professional standards of quality.
F689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) The facility failed to follow fall policy including documenting unwitnessed falls and 72-hour follow-up for one sampled resident.
F756 Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5) The facility failed to provide monthly pharmacy medication regimen reviews and physician responses for two sampled residents.
F757 Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6) The facility failed to ensure drug regimens had adequate indications and diagnoses for five sampled residents and one supplemental resident.
F758 Free from Unnec Psychotropic Meds/PRN Use CFR(s): 483.45(c)(3)(e)(1)-(5) The facility failed to ensure psychotropic drugs were used appropriately and monitored for one sampled resident.
F812 Food Procurement, Store, Prepare, Serve, Sanitary CFR(s): 483.60(i)(1)(2) The facility failed to maintain a sanitary kitchen environment, including pest control and food storage, affecting all residents.
F880 Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) The facility failed to maintain an infection prevention and control program including TB testing and reporting communicable diseases.
Report Facts
Facility census: 98
Licensed capacity: 120
Sampled residents: 20
Deficiencies cited: 7
Inspection Report
Life Safety
Census: 98
Capacity: 120
Deficiencies: 15
Date: Aug 10, 2022
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements for monitoring inside temperatures during power outages and HVAC failures. Deficiencies were also found in emergency lighting inspections, hazardous area fire resistance ratings, sprinkler system outages, fire extinguisher maintenance, electrical system maintenance, and staff training on emergency procedures.
Deficiencies (15)
E015: The facility failed to establish and maintain a comprehensive Emergency Preparedness plan including monitoring inside temperatures during power outages and HVAC failures, potentially affecting all residents and staff.
K291: The facility failed to ensure monthly and yearly emergency light inspections were itemized and conducted properly, affecting multiple smoke zones and residents.
K321: Doors to hazardous areas lacked proper fire resistance ratings and self-closing devices, affecting multiple smoke zones and residents.
K354: The sprinkler system was out of service for more than four hours without adequate fire watch procedures, affecting all residents and staff.
K355: The kitchen's Class K fire extinguisher was not located along an exit pathway, posing a hazard in one smoke zone.
K900: Staff were not properly instructed on the location and use of the remote stop button for the emergency generator, affecting all residents and staff.
K914: The facility failed to provide itemized annual inspection records for all bedside electrical receptacles in resident rooms, affecting multiple smoke zones.
K918: The facility failed to provide comprehensive documentation and maintenance for electrical panels and circuit breakers, affecting multiple smoke zones.
A2008: Hazardous areas were not properly separated by fire-resistant construction and self-closing doors as required.
A2016: Fire extinguishers lacked proper monthly pressure checks and labeling in accordance with NFPA standards.
A2036: Sprinkler system was out of service for more than four hours without immediate notification and fire watch, violating regulations.
A2050: Emergency lighting was not tested and maintained to provide sufficient intensity for safety in all exit and corridor areas.
A3030: Electrical wiring and equipment were not maintained according to NFPA standards, risking safety hazards.
A4013: The facility lacked operational policies and procedures to ensure resident health and safety, including emergency preparedness and infection control.
A4022: The facility failed to provide in-service orientation and continuing education for staff on emergency protocols and resident rights.
Report Facts
Facility census: 98
Total licensed capacity: 120
Number of smoke zones: 5
Number of resident rooms inspected: 68
Number of breaker panels inspected: 21
Number of breaker locations: 44
Inspection Report
Plan of Correction
Census: 31
Deficiencies: 1
Date: Jan 26, 2022
Visit Reason
The inspection was conducted to assess compliance with tuberculosis (TB) screening requirements for residents and staff at the facility.
Findings
The facility failed to administer the required two-step TB skin test to two sampled employees, as evidenced by missing documentation of the second step. The Director of Nursing acknowledged the issue and stated corrective actions would be taken.
Deficiencies (1)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to administer the required two-step TB skin test to two sampled employees, missing documentation of the second step.
Report Facts
Facility census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Technician A | Named in TB skin test deficiency | |
| Medication Technician B | Named in TB skin test deficiency |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Nov 18, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to protective oversight failures for a resident who was found deceased with their head and neck stuck between a bed rail and a Low Air Loss Mattress (LALM).
Complaint Details
The complaint investigation determined the violation was at imminent danger Class I level. The resident was found deceased on 11/10/21 with head and neck stuck between bed rail and LALM. The facility implemented corrective actions and a final revisit was planned to verify compliance.
Findings
The facility failed to provide protective oversight for one sampled resident by not ensuring proper assessment prior to use of bed rails and LALM, and failed to educate staff on monitoring these devices. The resident was found deceased with their head and neck stuck between the bed rail and LALM, resulting in a Class I deficiency.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight for one resident by not ensuring assessment prior to use of a quarter bed rail with a Low Air Loss Mattress and failed to educate staff on monitoring these devices. The resident was found deceased with head and neck stuck between the bed rail and mattress.
Report Facts
Facility census: 34
Residents sampled: 5
Residents with bed rails removed: 7
Residents with quarter rails removed: 2
Residents with bed canes identified: 4
Staff trained: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AL DON | Assisted Living Director of Nursing | Notified physician, coroner, police; involved in corrective actions and interviews |
| CMT A | Certified Medication Technician | Observed resident found on floor and participated in interviews |
| CNA A | Certified Nurse Assistant | Called to resident's room and assisted with resident found on floor |
| Administrator | Administrator | Reported hospice advised to contact coroner and police; involved in interviews and Plan of Correction |
Inspection Report
Routine
Deficiencies: 0
Date: Oct 15, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 20, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 18, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jan 19, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 27, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 05/27/2020 to assess compliance with CMS and CDC recommended practices and 42 CFR 483.73 regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
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 |
Inspection Report
Annual Inspection
Census: 104
Deficiencies: 6
Date: Nov 5, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations for the Villages of Jackson Creek nursing facility.
Findings
The facility was found deficient in multiple areas including dialysis coordination, pharmacy services, medication regimen review, medication storage, infection control, and labeling of drugs and biologicals. Several residents' records and medication practices did not meet regulatory requirements.
Deficiencies (6)
F698 Dialysis: The facility failed to ensure coordination of care between the facility and dialysis center and did not complete dialysis communication sheets for a resident.
F755 Pharmacy Services: The facility failed to ensure narcotic counts were done every shift with proper verification signatures.
F756 Drug Regimen Review: The facility failed to ensure the pharmacy consultant identified irregularities in residents' medication orders for PRN psychotropic medications with appropriate duration limits.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to ensure PRN psychotropic medication orders were limited to 14 days and properly evaluated for extension.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure proper storage of medications, including expired medications, open dates, and cleanliness of medication carts.
F880 Infection Prevention & Control: The facility failed to complete appropriate hand washing and glove changing during perineal care for sampled residents.
Report Facts
Facility census: 104
Missing narcotic count signatures: 75
Missing narcotic count signatures: 25
Deficiency sample size: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to dialysis communication sheets and narcotic count findings |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) F | Interviewed regarding dialysis communication worksheet |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding dialysis communication worksheet |
| Certified Medication Technician | Certified Medication Technician (CMT) D | Interviewed regarding narcotic counts |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) D | Interviewed regarding narcotic counts |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) E | Interviewed regarding narcotic counts |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) G | Interviewed regarding medication orders and PRN alprazolam |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) E | Interviewed regarding resident behavior and medication |
Inspection Report
Life Safety
Deficiencies: 0
Date: Nov 5, 2019
Visit Reason
The inspection was conducted as an Emergency Preparedness portion of the Life Safety Code survey to assess compliance with emergency preparedness and life safety regulations.
Findings
The facility was found to be in compliance with the requirements for Emergency Preparedness under 42 CFR 483.73 and met the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA). No deficiencies were cited during this inspection.
Inspection Report
Annual Inspection
Census: 115
Deficiencies: 6
Date: Oct 23, 2018
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for the Villages of Jackson Creek nursing facility.
Findings
The facility was found deficient in multiple areas including medication administration, accident hazards, respiratory care, food safety, infection prevention and control, and antibiotic stewardship. Several residents were observed with unsafe medication practices and improper oxygen tubing management. The facility failed to maintain sanitary food preparation conditions and implement an effective antibiotic stewardship program.
Deficiencies (6)
F658 Services Provided Meet Professional Standards: The facility failed to ensure staff followed professional standards of care during medication administration, including dropping medication on the floor and improper disposal of loose tablets in a resident's medication drawer.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure medications were administered properly and not left at the bedside for one resident who was not assessed for self-administration ability.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure oxygen tubing and nebulizer masks were properly labeled, stored off the floor, and dated for three sampled residents.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The dietary staff failed to maintain sanitary conditions during food preparation, including improper hair restraints and inadequate sanitizing of food contact surfaces.
F880 Infection Prevention & Control: The facility failed to maintain an effective infection prevention program, including improper use of personal protective equipment and inadequate staff training on infection control procedures.
F881 Antibiotic Stewardship Program: The facility failed to implement a facility-wide antibiotic stewardship program that included antibiotic use protocols and monitoring.
Report Facts
Facility census: 115
Sampled residents: 23
Inspection Report
Life Safety
Census: 115
Capacity: 120
Deficiencies: 2
Date: Oct 23, 2018
Visit Reason
The inspection was conducted as a Life Safety Code survey to evaluate the facility's compliance with emergency preparedness and fire safety regulations.
Findings
The facility failed to meet the requirements for conducting quarterly fire drills with complete documentation on all shifts. The fire drills lacked thoroughness in recording key elements such as alarm activation, staff response times, and evacuation procedures.
Deficiencies (2)
K712 Fire Drills: The facility failed to conduct quarterly fire drills with required documentation on all three shifts, affecting 115 residents. Documentation lacked details on alarm activation, staff response, resident relocation, corridor door closure, egress routes, and fire alarm transmission.
A2061 Fire Drill Requirements, Evacuation: The facility did not meet the regulation requiring twelve annual fire drills including a simulated resident evacuation involving the local fire department or emergency service at least once a year.
Report Facts
Facility census: 115
Licensed capacity: 120
Required annual fire drills: 12
Unannounced fire drills per shift: 1
Unannounced fire drills per year: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding fire drill discrepancies and corrective actions |
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