Average — CMS composite of the measures below.
A standard survey is most likely before 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 Jackson Ridge Healthcare Center during CMS and state inspections, most recent first.
Staff did not consistently follow the Dietician-approved pureed menu or portion sizes, resulting in several residents receiving incorrect, insufficient, or burned food portions. One resident with significant weight loss was among those affected. Staff interviews revealed recurring issues with running out of pureed food and inconsistent adherence to menu and portioning procedures, while facility policies lacked clear direction for following the approved menu.
Staff stored wet dishes and utensils directly above food preparation areas and transported uncovered food to resident rooms, despite facility policies requiring dry equipment and covered food during transport. Additionally, hot foods were served below the required holding temperature, as confirmed by staff interviews and policy review.
Surveyors observed staff placing wet dishes and utensils into storage and above food preparation areas, despite previous training and policies requiring dishes to be dry before storage. Required signage was missing, and staff interviews revealed inconsistent awareness and adherence to proper procedures, resulting in a repeated deficiency related to dish sanitation.
A resident with severe cognitive impairment and a history of weight loss was not consistently provided meals according to her care plan, which specified set-up and cueing for eating in her preferred recliner location. Staff did not offer meal trays or redirect her appropriately during meal times, despite being aware of the care plan instructions, resulting in missed meal opportunities.
Staff failed to properly sanitize a blood glucose meter used for multiple residents, placing supplies on unclean surfaces without a barrier and not following manufacturer instructions for cleaning and disinfection. Staff interviews revealed inconsistent understanding of required procedures, and the facility policy lacked guidance on using clean barriers during blood glucose checks.
The facility failed to follow proper food handling and sanitation practices. A cook did not allow dishes to air dry, reused a wet towel without sanitizing, and handled a scoop with bare hands after it fell into food. Interviews revealed a lack of awareness and adherence to sanitization procedures, and the facility's policy lacked specific directions for sanitizing the food prep area.
A resident with dysphagia reported that food was not served hot enough, and observations confirmed that meals were served below required temperatures. Despite training, dietary staff failed to maintain proper food temperatures, as evidenced by temperature logs and sample plate tests.
A resident in a LTC facility was unable to receive assistance due to a malfunctioning call light system, which failed to alert staff. The issue was widespread, affecting multiple units, and required staff to make visual checks. Despite attempts to fix the problem, the system remained unreliable. The DON and Administrator were unaware of the extent of the malfunction, indicating a lack of communication and monitoring.
The facility failed to notify the physician and family of significant changes in condition for two residents. One resident suffered a fall resulting in a skull fracture, and the family and physician were not notified until hours later. Another resident experienced a significant amount of bloody urine after a catheter insertion, with no documentation of physician notification. Facility policies requiring prompt notification were not followed.
A facility failed to update a resident's care plan to reflect the correct transfer status. The resident, with a history of atrial fibrillation, hypertension, and diabetes, was noted to have severely impaired cognition. Despite therapy recommendations and meeting notes indicating a change to assist with two staff using a front-wheeled walker, the care plan still required a mechanical lift. Staff interviews confirmed the care plan was not updated, and the Director of Nursing acknowledged the oversight.
A facility failed to maintain a safe environment by not repairing a malfunctioning bathroom light for a cognitively impaired resident and leaving door casings with sharp edges exposed in multiple rooms. Staff were aware of these issues but did not consistently report them, leading to a lack of maintenance action.
The facility failed to document that three residents received showers twice a week as required. Observations and record reviews revealed that residents with severe cognitive impairments did not have showers documented for several days across multiple months. The care plans required staff assistance for showers, but the facility's policy lacked clear directives for documenting refusals and re-approaching residents.
A facility failed to use proper transfer techniques for a resident requiring a two-person assist, and staff pushed two residents in wheelchairs without foot pedals, causing their feet to skim the floor. The care plans were not updated to reflect therapy recommendations, leading to improper practices.
A facility failed to secure narcotics and improperly disposed of an undated insulin pen. An LPN left an undated Lantus insulin pen unattended in a dining room with residents present, contrary to facility policy. Additionally, a narcotic drawer was found unlocked during a medication cart review, which was immediately corrected by an RN. The DON confirmed that narcotic drawers should always be locked and undated insulin pens disposed of immediately.
The facility failed to follow proper infection control techniques during food preparation and incontinence care. A cook did not use a paper towel to turn off the faucet after washing hands, contrary to policy. Additionally, a CNA improperly disposed of washbasin contents into the sink instead of the toilet after providing incontinence care to a resident with severe cognitive impairment.
Failure to Serve Dietician-Approved Pureed Menu and Portions
Penalty
Summary
The facility failed to serve the Dietician-approved menu to all five residents on pureed diets, as required. Observations revealed that staff did not consistently follow the approved menu or portion sizes, resulting in residents receiving incorrect amounts and, in some cases, burned or insufficient food. Specifically, staff prepared only the exact number of portions needed, did not account for food loss during preparation, and did not always use heaping measurements as expected. On one occasion, a resident received less than the required serving of peas and rice, with some food containing burned pieces, after staff ran out of pureed food. Staff interviews confirmed that running out of pureed food was a recurring issue, and there was inconsistency in following the portioning process and menu requirements. One resident affected by this deficiency had a documented significant weight loss, dropping from 129 pounds to 102.5 pounds over six months, without being on a physician-prescribed weight loss regimen. The facility's policies and procedures lacked clear direction for staff to follow the Dietician-approved menu, and staff did not consistently prepare extra servings to ensure all residents received the correct portions. The Consulting Dietician and Certified Dietary Manager both expected staff to prepare extra portions and use heaping measurements, but these expectations were not consistently met.
Deficiencies in Food Storage, Transport, and Temperature Control
Penalty
Summary
Staff were observed repeatedly storing wet dishes, including a glass measuring cup and spatulas, directly from the dish rack into storage and above food preparation areas. These items were visibly wet, with water droplets present, and were hung in a manner that allowed them to touch each other. This practice occurred while food was being prepared for the noon meal. Staff interviews confirmed that equipment is expected to be dry before storage to prevent bacterial growth, and that this expectation is part of staff training. Additionally, food was transported to resident rooms without being covered, specifically fruit bowls on trays for two residents, with the uncovered food being carried significant distances down the hallway. Staff interviews confirmed that all food items are required to be covered during transport and that appropriate covers are available. Food temperature checks at the end of meal service revealed that hot foods, such as mechanical soft beef cube pepper steak and pureed French onion rice, were served below the required holding temperature of 135 degrees Fahrenheit. Staff and policy confirmed the expectation that hot foods be held and served at or above this temperature.
Repeated Failure to Ensure Dishes Are Dry Before Storage
Penalty
Summary
The facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address a previously identified deficiency related to the storage of wet dishes in the kitchen. During the most recent survey, observations revealed that a dietary aide repeatedly placed wet dishes, including an 8-cup measuring cup and two spatulas with visible water droplets, into storage and above a preparation table where food was being prepared. Staff interviews indicated that employees had been trained to ensure equipment was dry before storage, but the practice was not consistently followed. Additionally, the required signage reminding staff to dry dishes before storage was missing from the designated area. Further interviews with dietary and administrative staff revealed a lack of awareness regarding the ongoing issue and the absence of the stop and dry sign. The QAPI plan and policy outlined the use of audits and monitoring, but the deficiency was repeated from a prior survey, indicating that the interventions were not effective in preventing recurrence. Documentation showed that newer staff had received some training, but the deficiency persisted, as evidenced by direct observation and staff statements.
Failure to Follow Care Plan for Resident with Weight Loss
Penalty
Summary
The facility failed to follow a care plan intervention for a resident with documented weight loss and severe cognitive impairment. The resident, who had diagnoses including hypertension, non-Alzheimer's dementia, and cerebrovascular accident, required extensive assistance for most activities of daily living but was independent with eating after staff set-up. The care plan specified that the resident liked to eat in a recliner in the main lobby and required cueing from staff due to frequent meal refusals. However, observations showed that staff did not consistently offer meals or set up food for the resident in her preferred location. On multiple occasions, the resident was not provided a meal tray or redirected to the table when meals were served, despite being present and independently drinking fluids. Staff interviews revealed inconsistent implementation of the care plan interventions. Certified Nursing Assistants and Registered Nurses acknowledged that while they attempted to redirect the resident to the table, they had not set up meal trays at the recliner as directed in the care plan. Staff relied on the kardex or electronic health record for care plan instructions but did not consistently follow the intervention to provide meals in the resident's preferred location. The Director of Nursing confirmed the expectation for staff to follow the care plan and noted that the resident often refused meals, with staff offering snacks throughout the day. The facility's policy required staff to be informed of care plan interventions and updates, but this was not effectively implemented for this resident.
Failure to Properly Sanitize Multi-Resident Blood Glucose Meter
Penalty
Summary
The facility failed to properly sanitize a blood glucose meter that was used for multiple residents. During a morning medication administration, a registered nurse used the blood glucose meter for one resident, placing the device and related supplies on the resident's unmade bed and bedside table without a clean barrier. After use, the nurse returned the meter to the medication cart without disinfecting it first, and when disinfection was performed, it was done with a Sani Cloth for less than the required wet time. The nurse did not follow the manufacturer's instructions, which require a two-step process using two wipes—one for cleaning and one for disinfecting—and a two-minute wet time for effective disinfection. Staff interviews revealed inconsistent knowledge of the required disinfection procedure and wet time. The facility's policy directed staff to use manufacturer-recommended wipes and follow product specifications but did not address the use of a clean barrier under supplies during blood glucose checks. The manufacturer's guidelines and CDC recommendations emphasize the importance of cleaning and disinfecting the meter between each resident to prevent the transmission of blood-borne pathogens. Documentation confirmed that multiple residents used the same blood glucose meter, and staff did not consistently follow proper cleaning and disinfection protocols as observed and described in interviews.
Improper Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food handling and sanitation practices, as observed during a survey. Staff A, a cook, was seen removing items from the clean dish rack without allowing them to air dry, stacking wet plastic plates and storage containers. Additionally, Staff A did not use a sanitizing solution when wiping down the food prep area, instead using a dry towel wetted with a spray nozzle. This towel was reused multiple times without proper sanitization, and no sanitizing solution bucket was present in the area during the observation. Furthermore, Staff A handled a scoop with bare hands after it fell into a steam table pan of fried rice, contrary to the facility's policy that requires avoiding contact with surfaces that come into contact with food. Interviews with the dietary supervisor and Staff A revealed a lack of awareness and adherence to proper sanitization procedures. The dietary supervisor acknowledged the availability of sanitation buckets, which were not utilized by Staff A during the observed incidents. Staff A admitted to being unaware of the sanitizing solution buckets until recently and described a process of using a wet towel for cleaning, which did not align with the facility's sanitation policy. A review of the facility's Sanitation of Dietary Equipment policy showed it lacked specific directions for sanitizing the food prep area, contributing to the observed deficiencies.
Deficiency in Serving Food at Proper Temperature
Penalty
Summary
The facility failed to serve food at a warm and palatable temperature during a meal service observed by surveyors. The deficiency was identified during an observation of a meal service where dietary staff recorded food temperatures that were below the required levels. Specifically, pureed fried rice, egg roll, and broccoli were served at temperatures ranging from 127 to 134 degrees Fahrenheit, which were below the facility's policy requirements for safe serving temperatures. A sample plate tested after meal service showed even lower temperatures, with broccoli at 116 degrees Fahrenheit and egg roll at 110 degrees Fahrenheit, indicating that the food was not served at an appetizing temperature. Resident #32, who has intact cognition and diagnoses including dysphagia, reported dissatisfaction with the food temperature, describing it as not hot enough. Interviews with dietary staff revealed that they had received training on proper food temperatures, yet the deficiency persisted. The dietary supervisor acknowledged the expectation that food should not be served at improper temperatures and stated efforts to monitor food temperatures daily. A review of food temperature logs showed multiple instances of food being served below the required temperatures, further supporting the deficiency observed by the surveyors.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility's call light system was found to be deficient as it failed to alert staff of call light activations to a central staff work area or directly to a staff member. This issue was observed when a resident was found in her bathroom, unable to receive assistance despite having activated the call light. The call light system, which should have illuminated a bulb outside the room and made a ringing noise at the nurses' station, failed to function as expected. Staff interviews revealed that the call light system was inconsistent, with some lights not buzzing or lighting up at the nurses' station, requiring staff to make visual checks instead. Further investigation showed that the problem was widespread, affecting multiple units within the facility. Staff members, including CNAs, RNs, and the housekeeping supervisor, confirmed that the call light system was unreliable, with some lights working intermittently or not at all. The maintenance supervisor attempted to fix the issue by replacing bulbs, but the problem persisted. The Director of Nursing and the Administrator were unaware of the extent of the malfunction, indicating a lack of communication and monitoring of the call light system. The facility's policy required staff to report malfunctions immediately, but this was not effectively implemented, leading to the deficiency.
Failure to Notify Physician and Family of Significant Changes in Resident Condition
Penalty
Summary
The facility failed to document the notification of the physician and family for two residents who experienced significant changes in their conditions. Resident #23, who was cognitively impaired and at risk for falls, suffered a fall resulting in a skull fracture. Despite the fall occurring in the morning, the family and physician were not notified until later in the afternoon, after the family requested the resident be sent to the emergency room. The facility's policy required immediate notification of the physician and family in such cases, but this was not adhered to, leading to a delay in appropriate medical evaluation and family awareness. Resident #49, who was severely cognitively impaired and had a history of renal insufficiency, experienced a significant change in condition with the return of a large amount of bloody urine after a Foley catheter was inserted. There was no documentation indicating that the physician was notified of this change. The facility's policy required notification of the physician for significant changes in a resident's condition, but this was not followed, resulting in a lack of timely medical intervention. Interviews with staff, including the LPN and DON, revealed that the expected protocol for notifying physicians and families was not followed in these cases. The facility's policies clearly outlined the need for prompt notification of changes in a resident's condition, but these procedures were not implemented, leading to deficiencies in the care provided to the residents.
Failure to Update Resident Transfer Status in Care Plan
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident #22, to reflect the correct transfer status. The resident had a history of atrial fibrillation, hypertension, and diabetes mellitus, and was noted to have severely impaired cognition with a BIMS score of 3. The Minimum Data Set (MDS) indicated that the resident was dependent on staff for transfers. However, the care plan, dated 6/4/24, stated that the resident required a mechanical lift with two staff for transfers. Therapy recommendations on 6/13/24 and subsequent meeting notes on 6/14/24 indicated a change to assist with two staff using a front-wheeled walker, but this was not updated in the care plan. Interviews with staff revealed that the care plan was not updated despite communication from occupational therapy to the MDS coordinator. Staff J, a CNA, confirmed that the care plan still indicated the use of a mechanical lift, and Staff I, an LPN, stated that changes in transfer status should be reflected in the care plan. The Director of Nursing acknowledged that the care plan should have been updated during the Medicare meeting. Staff K from occupational therapy confirmed that the resident required a two-person assist with a front-wheeled walker, and the communication form was provided to the MDS coordinator for updating the care plan.
Facility Fails to Maintain Safe Environment Due to Lighting and Structural Issues
Penalty
Summary
The facility failed to maintain a safe and homelike environment for its residents, as evidenced by the malfunctioning bathroom light in a resident's room and damaged door casings in multiple rooms. A cognitively impaired resident, who required substantial assistance with daily activities, was observed using the bathroom in the dark due to a non-functioning light. Despite the resident's request to turn on the light, it only illuminated after the staff had completed assisting the resident. Staff interviews revealed that the light issue was known to occur frequently in the mornings, but no work orders had been submitted to the maintenance supervisor to address the problem. Additionally, several rooms in Unit 2 had door casings with missing pieces and sharp edges exposed, posing a potential safety hazard. Staff members were aware of the damaged door casings and were expected to report such issues in the maintenance book, but the maintenance supervisor had only been informed of two rooms needing repair. The maintenance supervisor was waiting for parts to arrive and noted that the previous corporation had restricted purchasing necessary repair items. The Director of Nursing was unaware of the lighting issues and expected staff to complete work orders for maintenance needs, which were not being consistently reported or addressed.
Failure to Document Resident Showers
Penalty
Summary
The facility failed to document that three residents received showers twice a week as required. Resident #6, who is severely cognitively impaired with a BIMS score of 03, was observed with greasy hair and a slight odor, indicating a lack of regular hygiene care. The review of Resident #6's shower records for May, June, and July 2024 showed multiple instances where no showers were documented for several consecutive days. The care plan for Resident #6 required staff to assist with showering twice a week and as needed, with additional assistance if the resident was combative. Similarly, Resident #34, also severely cognitively impaired with a BIMS score of 03, had no showers documented for several days in May, June, and July 2024. The care plan directed staff to provide assistance with showers twice a week. Resident #38, with a BIMS score of 03 and requiring substantial assistance, also had missing shower documentation for several days in June and July 2024. The facility's policy did not adequately direct staff on the procedure for documenting shower refusals or re-approaching residents, as noted by the DON during an interview.
Improper Transfer and Wheelchair Techniques Observed
Penalty
Summary
The facility failed to utilize proper transfer techniques for Resident #22, who was identified as having severe cognitive impairment and was dependent on staff for transfers. During an observation, a CNA was heard completing a transfer of Resident #22 with only one person and a gait belt, contrary to the care plan which required a two-person assist with a front-wheeled walker. The care plan had not been updated to reflect the therapy recommendations, leading to improper transfer techniques being used. Additionally, the facility failed to use proper techniques when pushing residents in wheelchairs. Resident #23, who was cognitively impaired and at risk for falls, was observed being pushed in a wheelchair without foot pedals, causing his feet to skim the floor. Similarly, Resident #27, who was moderately cognitively impaired and dependent on staff for assistance, was also pushed in a wheelchair without foot pedals, leading to his feet skimming the floor during transport. The Director of Nursing and other staff acknowledged that the care plans should have been updated to reflect the correct transfer and transport techniques. The facility's policy on transfer techniques directed staff to obtain help as necessary, but this was not followed, resulting in the deficiencies observed.
Improper Pharmaceutical Practices in LTC Facility
Penalty
Summary
The facility failed to ensure proper pharmaceutical services by not securing narcotics and improperly disposing of an undated insulin pen. During an observation, a Licensed Practical Nurse (LPN) was seen removing a Lantus insulin pen from a medication cart that was not dated when opened. The LPN left the undated pen on top of the medication cart in the dining room, unattended, while multiple residents were present. The LPN admitted in an interview that she forgot to dispose of the undated pen immediately, which is against the facility's policy. Additionally, during a review of a medication cart on Unit 1, it was found that the narcotic drawer was not locked. A Registered Nurse (RN) verified this and immediately locked the drawer. The Director of Nursing (DON) confirmed that narcotic drawers should be locked at all times and that undated insulin pens should be disposed of immediately. The facility's policy on medication storage, last revised in April 2007, states that compartments containing drugs and biologicals should be locked when not in use, and carts should not be left unattended if open.
Infection Control Deficiencies in Hand Washing and Incontinence Care
Penalty
Summary
The facility failed to demonstrate proper hand washing techniques during food preparation and handling, as well as during incontinence care for a resident. During an observation of the puree process, a cook, identified as Staff A, washed her hands multiple times but did not follow the facility's hand washing policy. She turned off the faucet with her wet hand and used her bare hand to operate the paper towel dispenser, contrary to the policy that requires using a dry paper towel to turn off the faucet to prevent contamination. Interviews with the dietary supervisor and Staff A confirmed that hand washing audits were conducted, but Staff A was not consistently using a paper towel to shut off the faucet. Additionally, the facility failed to utilize proper infection control techniques during incontinence care for a resident identified as severely cognitively impaired and dependent on staff for personal hygiene. During an observation, Staff E, a CNA, used a washbasin to clean the resident after a bowel movement but emptied the washbasin into the sink instead of the toilet, which is against the expected procedure. Interviews with staff, including the DON, confirmed that the washbasin should be emptied into the toilet after providing incontinence care. The facility's policy on incontinence care did not include instructions for disposing of the washbasin contents into the toilet.
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Illustrative
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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.
Illustrative
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Nursing homes near Maquoketa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maquoketa Care Center | 0.4 mi | ★★★★★ | 1 | 0 |
| Fieldstone Of Dewitt | 17.7 mi | ★★★★★ | 2 | 0 |
| Wheatland Manor | 18 mi | ★★★★★ | 2 | 0 |
| Mill Valley Care Center | 18.1 mi | ★★★★★ | 0 | 0 |
| Clarence Nursing Home | 23.3 mi | ★★★★★ | 0 | 0 |
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