Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Creek Post Acute during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, Huntington’s Disease, and a cognitive communication deficit fell out of bed, sustaining a head injury, mouth laceration, facial bruising, and leg injuries, and was transported to the hospital for treatment. Facility policies required staff to notify the resident’s representative of falls, injuries, significant condition changes, and hospital transfers, and the resident’s DPOA was clearly listed as the emergency contact and responsible party. An LPN on duty notified the physician, DON, and ambulance but did not notify the DPOA, despite knowing this was required, and the DPOA only learned of the incident about eight hours later from a non-nurse family friend who worked at the facility.
Unsanitary kitchen conditions and improper hand hygiene during food prep. Surveyors observed dust on the walk-in cooler ceiling and fans, debris and a slimy brown substance in the cooler, food residue on the knife holder area, and dirty floors under cooking equipment. Dietary Assistant A dropped a probe thermometer on the floor, handled utensils and food without washing hands or changing gloves, did not sanitize the counter after placing the thermometer on it, and entered the kitchen without hand hygiene before handling ready-to-eat items.
Dust buildup was observed on two ceiling fans in the 400 Unit lobby, under the beds in two resident rooms, and on the ceiling vent in the beauty salon. The Maintenance Director did not know when the fans were last cleaned, and the Housekeeping Supervisor and Maintenance Director gave conflicting statements about whether housekeeping or maintenance was responsible for cleaning the salon vent and ceiling fans.
Missing Detailed Hospice Physician Orders: Surveyors found that detailed physician orders for Hospice services were not transcribed to the POS for four residents. Although the chart contained other references to Hospice, including care plans, banners, and Hospice records, the POS often only showed a referral or evaluation order and did not include the admitting Hospice order with the supporting dx and Hospice provider name. Staff, including an LPN and the DON, stated they expected those detailed Hospice orders to be on the chart.
The facility failed to maintain infection control practices for three residents. A resident with an indwelling catheter had tubing dragging on the floor under a wheelchair while in pain and later was diagnosed with a UTI. Another resident with a wound vac had the device placed on the floor beside the bed without a protective barrier on multiple observations. A third resident receiving incontinence care was observed with an LPN and hospice CNA using the same gloves to clean the peri area and then touch other resident items and room items without changing gloves or performing hand hygiene.
Unsafe Water Temperatures and Poor Facility Maintenance: Surveyors found multiple resident room faucets with hot water above 120 F and one room below 105 F, affecting at least 21 residents. They also observed peeled laminate flooring in resident rooms, debris buildup in the employee breakroom, and black residue with a foul odor around the dish machine drain. The Maintenance Director said the hot water heaters were set between 138 F and 140 F and that hot water in part of the 300 Unit could take 5 minutes or longer to get hot.
A resident with Parkinson’s disease, dementia, schizophrenia, and Alzheimer’s disease was observed multiple times sitting in a wheelchair with dried brown and white food debris dripping down the armrest and side of the chair. Staff gave inconsistent accounts of who was responsible for cleaning wheelchairs, with CNA and LPN stating night shift handled it and the DON saying night shift had a weekly and as-needed schedule, but the debris remained on the chair across several observations.
A resident with cerebral palsy, hemiplegia, significant cognitive impairment, and high skin breakdown risk did not consistently receive ordered ROM-related care. Staff observed the resident without the right-hand palm guard and at times without bunny boots, with the boots often left on a tray table or out of reach. The record lacked documentation of refusals or application times for the palm guard, and staff interviews confirmed the resident often refused the device and that the bunny boot order was not properly reflected on the POS.
Failure to obtain a physician order and nursing assessment for Foley self-care: A resident with a Foley catheter, bladder dysfunction, and a history of UTI was documented as receiving staff catheter care every shift, but the chart had no order or nursing assessment for the resident to perform any part of his or her own catheter care, including emptying the drainage bag. The resident said he or she did some catheter care independently, while staff gave mixed reports about who was responsible for catheter care and monitoring.
A resident with cerebral palsy, dysphagia, aphasia, hemiplegia, and significant weight loss was dependent on staff for meals and was ordered MedPass 7 oz three times daily. Record review and observation showed the supplement was not consistently provided with meals, and the MAR/TAR only showed checkmarks that it was given without documenting how much was consumed. Staff, including CNA, CMT, RN, RD, DON, and the unit manager, acknowledged that intake should be documented, but the chart lacked evidence of actual supplement consumption.
A resident with a PEG tube, severe cognitive impairment, and dysphagia had medications given through the tube without placement verification or residual checks, while the chart lacked clear PEG placement directions. The facility also did not consistently document or monitor ordered tube feeding and water flush amounts, and observations showed feeding and flush bags that were not labeled with the required date, time, or staff initials and did not consistently match the current order.
A facility failed to complete monthly MRRs and follow consultant pharmacist recommendations for two residents. One resident with chronic pain syndrome and anxiety had repeated pharmacist recommendations related to Morphine Sulfate and Lorazepam that remained unchanged in the TAR for months, while the other resident with hypertensive heart disease and CKD had missing MRR documentation for multiple months. Staff said the MRR process was handled by unit managers and the wound nurse, and the DON stated there was no back-up system after the pharmacy change.
A resident with Parkinson's disease and intact cognition repeatedly did not receive oatmeal and milk listed on the breakfast meal ticket for three mornings in a row. The resident said this happened frequently and that nursing staff were told, but the items still were not provided. Staff said residents on room trays were expected to request missing items, while the DON said CNAs were supposed to double check meal tickets and notify the kitchen when items were missing or a resident wanted a change.
A resident with end stage renal disease and diabetes was not given prescribed Sevelamer at lunch after refusing it at breakfast, and this was not communicated to the charge nurse or physician. Additionally, sliding scale insulin was administered late after lunch without notifying the physician. Staff failed to document refusals and delays properly or follow required notification protocols.
A resident with complex medical needs did not receive prescribed medications and treatments as ordered, including missed doses of Sevelamer and delayed insulin administration. Staff failed to document medication refusals and omissions accurately, did not communicate these issues to management, and did not update the care plan to address ongoing medication refusals. Facility policies lacked guidance on sliding scale insulin, and the MAR contained inaccurate entries.
A resident with end stage renal disease did not receive coordinated care due to a breakdown in communication between the facility and the dialysis provider. For several weeks, there was no written or verbal exchange of information regarding the resident's dialysis treatments. Staff and the resident confirmed that forms with vital signs and treatment details were not consistently shared or retrieved, and the expected process for reporting was not followed by either the facility or the dialysis clinic.
A nurse failed to follow infection prevention protocols during a central venous catheter dressing change for a resident on hemodialysis. The nurse did not wear a gown or mask, did not use a barrier for supplies, and did not cleanse the catheter site before applying a new dressing, contrary to facility policy and CMS guidance. The DON confirmed that required procedures, including use of PPE and site cleansing, were not followed.
A resident with end-stage renal disease missed two dialysis sessions due to a lack of transportation arrangements, leading to severe health complications and hospitalization. The facility's staff failed to communicate and coordinate effectively, resulting in the resident not receiving dialysis for six days. The deficiency was identified as an immediate jeopardy situation.
A resident with ESRD missed two dialysis sessions due to transportation issues, and the facility failed to notify the physician, family, or department heads in a timely manner. Additionally, the resident experienced an unwitnessed fall, and the necessary notifications were not made promptly. This lack of communication and coordination led to the resident's hospitalization for elevated potassium and low hemoglobin levels.
The facility failed to maintain cleanliness and proper labeling in the kitchen, with grime buildup, leaks, and debris observed. Dietary Aide's hair was not fully covered, and milk was stored at an unsafe temperature. The Dietary Manager and Maintenance Director had attempted to address some issues, but problems persisted, potentially affecting all 105 residents.
The facility failed to maintain commode risers in an easily cleanable condition and did not ensure mechanical lifts on the 300 and 400 Halls were in sound condition. Observations revealed issues with the commode risers and mechanical lifts, which staff did not notice or document properly. This potentially affected 14 residents who used these devices.
The facility failed to properly assess and monitor medication administration for a resident, leaving medications at the bedside without proper authorization. Additionally, two residents with severe cognitive impairments were incorrectly allowed to keep OTC medications at their bedside due to errors in the electronic medical record system.
The facility failed to ensure pureed eggs were palatable and hot foods on room trays were maintained at a safe temperature during breakfast. Observations showed the Dietary Manager did not follow a recipe or add seasonings, and room trays were delivered over an extended period, causing food to cool. Residents reported consistently receiving cold meals, and temperature checks confirmed food was below the recommended 120 F.
The facility failed to ensure that food in the resident use refrigerator was labeled with the resident's name and the date the food item was brought in, as per the facility's policy. Several items, including salad dressings, mayonnaise, coffee creamer, relish, restaurant sauce, and dietary supplements, were found without proper labeling. Interviews revealed that the refrigerator had not been cleaned recently, leading to the presence of expired and unidentified food items.
The facility failed to ensure proper hand hygiene, use of barriers for supplies, and cleansing of the glucometer during blood glucose monitoring and insulin administration for three residents. Staff did not follow the facility's policies, leading to multiple instances of non-compliance.
The facility failed to complete a required PASARR Level I screening in a timely manner for a resident with major mental illness, including PTSD and depression. The social worker did not realize the screening was required for private pay residents, leading to a delay in the assessment and care planning process.
The facility failed to provide an ongoing activity program based on a comprehensive assessment and care plan for two residents. Both residents, who were receiving hospice care and had multiple diagnoses, were observed to spend most of their time not engaged in meaningful activities. Interviews revealed staffing and time management issues, as well as difficulties with a new electronic health records system, contributing to the deficiency.
The facility failed to ensure timely fall prevention interventions for a resident with a history of falls and did not use a gait belt for another resident requiring assistance with transfers. The deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in updating care plans and following transfer protocols.
A facility failed to ensure a resident requiring dialysis received ongoing assessments and accurate documentation of the dialysis site. The resident's care plan and progress notes lacked specific details, and interviews revealed that the dialysis site was not regularly assessed or documented. The DON confirmed the expectations for site assessments, but due to the absence of a unit manager and proper documentation, necessary assessments were assumed not performed.
The facility failed to ensure a comprehensive PTSD care plan and staff education for a resident with PTSD. The care plan lacked detailed information on the resident's trauma history, triggers, and guidance for staff. Interviews revealed staff were unaware of the resident's PTSD diagnosis and specific triggers, indicating a gap in the facility's trauma-informed care process.
A facility failed to consider all appropriate alternatives before installing bed rails for a resident with a history of falls. Despite the facility's policy against using bed rails as restraints, the rails were installed primarily due to the family's insistence, without thorough assessment or documentation of other interventions.
A facility failed to ensure bed rails for a resident with multiple diagnoses were compatible with the bed and safely installed. The bed rail's measurements were outside safety guidelines, and the adjustable tightening knob was loose, posing a risk for entrapment. Staff had not reported any issues, and the Maintenance Supervisor did not perform safety audits, relying on nursing staff to report problems.
Failure to Notify Resident Representative After Fall With Injury and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s representative of a fall with injury and subsequent transfer to the hospital, as required by facility policy. The facility had written policies titled “Assessing Falls and Their Causes” and “Change in a Resident’s Condition or Status,” which directed staff to notify the resident’s family or representative when a resident fell, sustained an injury, experienced a significant change in condition, or required transfer to a hospital or treatment center. Despite these policies, the resident’s Durable Power of Attorney (DPOA), listed as the emergency contact and responsible party in the admission record, was not notified when the resident experienced a fall and was sent to the hospital. The resident involved had moderate cognitive impairment and diagnoses including Huntington’s Disease and a cognitive communication deficit, as documented on a Quarterly MDS. On the night of the incident, the resident’s roommate alerted the nurse that the resident had fallen out of bed. When the nurse entered the room, the resident was found on the floor with blood on the mouth and a red mark on the back of the head. The nurse contacted an ambulance, the DON, and the resident’s physician, and the resident was transported to the hospital, where the resident received sutures for a laceration sustained from the fall. During interviews, the LPN who was the charge nurse at the time acknowledged being aware that the resident had a responsible party and was not considered his or her own decision-maker, and also acknowledged knowing that the DPOA should have been notified of the fall and hospital transfer. The LPN stated that the DPOA was not notified and that this was due to forgetting to make the call. The DPOA later learned of the fall and injuries indirectly from a family friend who worked at the facility approximately eight hours after the incident, rather than from the responsible nursing staff. The DPOA reported not being informed by the charge nurse, expressed that they would have wanted to be present at the hospital, and described the resident’s injuries, including a laceration requiring sutures, facial bruising and swelling, and leg injuries.
Unsanitary kitchen conditions and improper hand hygiene during food preparation
Penalty
Summary
The facility failed to maintain the walk-in cooler ceiling, fans, and floors in a clean condition, and also failed to keep the floors under the cooking equipment area clean. During observation, the knife holder by the dish machine area had food debris on it, with droppings of food residue on the ledge below it. The walk-in cooler also had dust on the ceiling and fans, a slick slimy brown substance between the shelves by the wheels on the left-hand side, debris under the shelves, and six individual tubs of butter stored on the floor under the shelves on the left side of the cooler. During lunch meal preparation, Dietary Assistant A dropped a probe thermometer on the floor, picked it up, placed it on the table, and then touched the scrapper, spatula, and tongs before wiping the thermometer with sanitizer wipes and using it to probe hot dogs. Dietary Assistant A did not wash hands or change gloves after the thermometer fell on the floor, and the counter surface was not wiped down or sanitized after the thermometer was placed on it. Dietary Assistant A also entered the kitchen without washing hands, put on gloves, handled a cooked hamburger patty with cheese, placed it in the microwave, retrieved lettuce and a tomato slice from the walk-in cooler, and gave them to the cook for the cheeseburger. The assistant then removed gloves and handled empty soup cans on the counter. The Dietary Manager stated that staff should wash hands and change gloves whenever they drop something on the floor or touch a non-food surface before touching food, and should wash hands when entering the kitchen area.
Dust Buildup in Resident Areas and Beauty Shop
Penalty
Summary
The facility failed to maintain two ceiling fans in the 400 Unit lobby free from dust buildup, failed to keep the floors in resident rooms free from dust and debris buildup, and failed to maintain the ceiling vent in the beauty shop free from dust buildup. During observation, the Maintenance Director saw dust on two ceiling fans in the 400 Unit lobby where about seven residents were sitting and said he/she did not know the last time the fans were cleaned. The Housekeeping Supervisor stated that cleaning the ceiling fans was the responsibility of the maintenance department and that the fans should be cleaned once per month. In two resident rooms, surveyors observed dust and debris buildup under the beds. The Housekeeping Supervisor stated that during regular mopping and sweeping, housekeeping staff should get under the beds to clean them and that the space under the beds in those resident rooms should not have dust and debris. In the beauty salon, surveyors observed a heavy buildup of dust on the ceiling vent. The Maintenance Director said it was the responsibility of housekeeping to clean the vent, while the Housekeeping Supervisor later stated that it is normally the Maintenance Director's duty to clean the vent.
Missing Detailed Hospice Physician Orders
Penalty
Summary
The facility failed to transcribe detailed physician orders for Hospice services on the Physician's Order Sheet for four sampled residents. Survey review found that the residents had Hospice involvement documented in other parts of the record, but the charted physician orders did not consistently include an order admitting the resident to Hospice services with the supporting diagnosis and the name of the Hospice provider. The facility's Hospice Program policy, revised January 2014, did not provide guidance on transcription of a detailed physician order for Hospice care services, and the facility did not provide its physician's order policy at exit. For one resident with cerebral palsy, cognitive communication deficit, dysphagia, aphasia, hemiplegia, and muscle weakness, nursing notes showed refusal of meals, limited intake, refusal to get up, and pain, with a conference call to the DPOA and agreement to resume Hospice services. The Hospice medical record showed Hospice was initiated with a diagnosis of senile degeneration of the brain, but the Physician's Order Sheet only showed an order for Hospice to assess and evaluate the resident and did not show a physician's order for Hospice services identifying the provider. For another resident with prostate cancer and palliative care, the face sheet and care plan identified Hospice involvement and the Hospice provider, but the Physician's Order Sheet only contained an order for the Hospice provider to evaluate and did not include a detailed admission order with the supporting diagnosis. For a third resident receiving end-of-life care, the MDS, care plan, and Hospice records showed the resident was on Hospice and had been admitted to a local Hospice service with ongoing visits, but the Physician's Order Sheet had no physician's order for Hospice services. For a fourth resident with Parkinson's disease with dyskinesia and fluctuations, dysphagia, dementia, paranoid schizophrenia, Alzheimer's disease, and heart failure, the admission sheet, MDS, and care plan showed the resident had been on Hospice since March 2025, but the Physician's Order Sheet did not list Hospice orders. Staff interviews confirmed they expected detailed Hospice orders on the Physician's Order Sheet, including the Hospice provider name and supporting diagnosis, but these orders were not present in the chart for the sampled residents.
Infection Control Failures With Catheter Placement, Wound Vac Storage, and Hand Hygiene
Penalty
Summary
The facility failed to ensure infection control practices to prevent cross-contamination with proper placement of medical devices. One resident admitted with ESRD, neuromuscular dysfunction of the bladder, moderate cognitive impairment, total assistance for toileting, and an indwelling catheter had catheter tubing observed dragging on the ground underneath a wheelchair while the resident was sitting by the nursing station after returning from dialysis. The resident was moaning in pain and repeatedly stated a desire to go to the hospital, reporting severe groin and lower back pain. The resident later returned from the emergency room with a diagnosis of UTI and a new antibiotic order, and the catheter tubing was again observed dragging on the ground underneath the wheelchair. A second resident admitted with osteomyelitis of the right ankle, cognitive communication deficit, and a right heel wound with wound vac therapy had the wound vac device observed on the floor beside the bed on multiple occasions. The device was seen inside a black carrying case on the floor without a protective barrier underneath it, and later was again observed on the ground next to the bed without a barrier. During wound care, the wound vac machine was on the ground on top of a barrier, and the wound nurse later hung the device on the side of the bed before leaving the room. The resident’s wound care plan included wound vac therapy at 125 mm Hg continuous suction. A third resident with post polio syndrome, palliative care, paraplegia, impaired mobility, and a catheter was observed during incontinence care with an LPN and hospice CNA using the same gloves while cleaning the resident’s peri area, applying skin protectant, reapplying the brief, adjusting the nasal cannula, handling the water pitcher and straw, attaching the call light, and repositioning the resident and bed items. Gloves were not changed and hand hygiene was not performed between peri care and touching other items or areas of the resident. Interviews with staff confirmed expectations that hand hygiene should be performed and gloves changed after peri care and before touching other items.
Unsafe Water Temperatures and Poor Facility Maintenance
Penalty
Summary
The facility failed to maintain resident-accessible hot water at handwashing faucets within the required temperature range in multiple resident rooms. Survey observations on 12/1/25 and 12/2/25 found several rooms with hot water temperatures above 120 F, including readings of 124.3 F, 128.4 F, 123.6 F, 125.5 F, 123.4 F, 125.0 F, 125.9 F, 126.6 F, and 126.8 F. One room also had hot water temperatures below 105 F, with readings of 66.8 F, 66.3 F, 67.2 F, and 66.0 F on separate checks. The report states this affected at least 21 residents in the listed rooms, and the facility census was 108 residents. The facility’s policy stated that plumbing fixtures requiring resident-accessible hot water must provide water thermostatically controlled between 105 F and 120 F at the faucet. During interview, the Maintenance Director stated the hot water heaters were set between 138 F and 140 F and were reset to 135 F, and said the hot water for part of the 300 Unit could get hot but could take 5 minutes or longer. He/she was not sure how the plumbing for the 300 Hall was arranged, although the circulating pump was working. The facility also had physical plant and sanitation issues observed by surveyors. A section of flooring in one resident room was peeled away from the subfloor, and another resident room had a large section of laminate flooring peeled away from the floor. In a non-resident area, surveyors observed a heavy buildup of debris between the refrigerator and the wall in the employee breakroom. In the kitchen area, surveyors observed black residue on the drain under the dish machine and a foul odor coming from that area; the Dietary Manager said the odor had been noticed for a couple of months and described the drain area as having black residue and a smell that might be coming from the grout, wall, and drain.
Wheelchair Left with Dried Food Debris
Penalty
Summary
The facility failed to maintain the cleanliness of a resident’s wheelchair, affecting the resident’s dignity. Resident #42 had Parkinson’s disease with dyskinesia and fluctuations, dysphagia, unspecified dementia with psychotic disturbance, paranoid schizophrenia, and Alzheimer’s disease. The quarterly MDS dated 9/29/25 showed the resident was not cognitively intact, used a wheelchair for mobility, and required substantial to maximal assistance for feeding and for all activities of daily living. During multiple observations from 12/2/25 through 12/4/25, the resident was seen sitting in the community room in the wheelchair while brown and white dried spilled food debris remained in a dripping formation all over the left armrest and down the outside of the wheelchair below the armrest. Staff interviews on 12/5/25 showed CNA E believed night shift was responsible for cleaning wheelchairs and said the resident’s wheelchair needed to be scrubbed, while LPN D also said night shift was responsible and stated there used to be a list for wheelchair cleaning but did not know what happened to it. The DON stated night shift had a schedule to clean all wheelchairs at least once a week and as needed, and said he/she did not know why there was debris on the resident’s chair.
Failure to Follow Orders for Palm Guard and Bunny Boots
Penalty
Summary
The facility failed to follow physician's orders for a resident with cerebral palsy, cognitive communication deficit, dysphagia, aphasia, hemiplegia, and muscle weakness who had significant cognitive impairment, upper and lower extremity impairment, and needed moderate to total assistance with dressing, grooming, bathing, and mobility. The resident's Braden Scale score was 11, indicating high risk for developing wounds. The care plan identified the resident as at risk for skin breakdown related to impaired mobility, incontinence, and impaired activities of daily living ability, and included interventions for bunny boots to both feet at all times as tolerated and a right hand palm guard. The resident had a physician's order for a palm guard on the right hand daily and off at night every shift, but observations showed the resident was often not wearing the palm guard and it was frequently found on a tray table, dresser, or not in use. There was no documentation showing the resident refused the palm guard, and there was no documentation showing when the palm guard was applied. A restorative nursing task also directed staff to place the splint on the resident's right hand if not already wearing it, but the restorative aide stated the resident often refused and that refusals were documented on paper first rather than in the medical record. The resident also had a prior physician's order for bunny boots to both feet at all times every day and night shift for prevention, but that order was discontinued on 11/17/25 and there was no current physician's order on the POS for soft boots despite staff stating the resident should wear them. Observations showed the resident was sometimes not wearing the bunny boots while in bed, with the boots left on a tray table or out of reach, although at other times the resident was observed wearing them. Interviews with the Wound Care Nurse, Rehabilitation Director, Restorative Aide, Unit Manager, and DON confirmed that the boots and palm guard were expected to be used, that documentation of refusals should have been present, and that the bunny boot order may have been discontinued by mistake.
Failure to Obtain Order and Assess Self-Care for Foley Catheter
Penalty
Summary
The facility failed to obtain and transcribe a physician order for a resident to provide his or her own indwelling Foley catheter self-care, and failed to complete a nursing assessment of the resident’s ability to perform any or all Foley catheter care. Resident #5 was admitted with neuromuscular dysfunction of the bladder and a history of UTI, and the catheter care plan documented a Foley catheter for urinary retention, obstructive uropathy, and history of stroke, along with a history of refusal of catheter care and changes. The care plan directed staff to provide catheter care every shift and monitor for signs and symptoms of infection, but it did not include a plan for the resident to perform self-care. Record review showed no documentation that the resident was assessed for the ability or knowledge to provide his or her own catheter care, including emptying the Foley drainage bag. The admission MDS indicated the resident was cognitively intact, able to understand others and make needs known, required total assistance for toileting, and was admitted with an indwelling catheter. During interview, the resident stated he or she had a Foley catheter since 2023, completed most personal care with minimal assistance, and did some catheter care, including emptying the drainage bag as needed. The active physician order sheet contained orders for nursing and care staff to provide Foley catheter care every shift and to change the catheter monthly and as needed, but there was no physician order for the resident to provide his or her own catheter care or for licensed staff to assess the resident’s ability to do so. Staff interviews reflected differing understanding of the resident’s catheter care responsibilities, with some stating the resident emptied the bag independently and others stating nursing should provide and monitor catheter care every shift. The DON stated a physician order and nursing assessment would be expected for any resident wishing to provide any part of his or her own catheter care.
Failure to Follow Supplement Orders and Document Intake
Penalty
Summary
The facility failed to follow physician orders for a resident who was dependent on staff for eating and who received nutritional supplements. The resident had diagnoses including cerebral palsy, cognitive communication deficit, dysphagia, aphasia, hemiplegia, and muscle weakness. The resident’s weight record showed a gradual decline over several months, and dietary notes documented ongoing weight loss while the resident was on a regular mechanical soft-ground meat diet with thin liquids, received MedPass supplement 7 ounces three times daily, and required assistance with meals in the dining room or in bed. The resident’s care plan identified the resident as cognitively incapacitated, on hospice services, at risk for rapid decline, altered nutrition, and weight loss. The plan included providing house supplements as ordered and evaluating the need for assistance while eating and drinking. However, the record review showed that the MAR and TAR only contained checkmarks indicating the supplement was provided, with no documentation of how much MedPass the resident actually consumed at each meal. The meal consumption record for a 30-day period contained no documented data, and the medical record did not show monitoring of supplement consumption or how much was consumed daily or at meals. Observation and interviews showed the resident did not receive the supplement with the meal during one dining room observation, and staff continued trying to feed the resident while the resident refused food. CNA staff stated the resident usually did not eat well and that supplements were not provided with meals. A nurse later approached the resident with a nutritional supplement, but the resident refused it. Family members reported that the resident would drink the supplement when it was given, and staff stated that supplements were given by CMTs or nurses, but they did not document how much was consumed. The RD, DON, and unit manager all stated that staff should document the amount consumed, but the record showed only that the supplement was given, not how much the resident drank.
PEG Tube Placement, Feeding, and Documentation Failures
Penalty
Summary
The facility failed to accurately assess a resident’s PEG tube placement and residual before administering medications through the tube. The resident had severe cognitive impairment, dysphagia following a cerebral infarction, and received more than 51% of nutrition through tube feeding. The record showed orders to check gastric residual every eight hours, but there were no PEG placement checks specified and no directions on how to check placement in the MAR/TAR, care plan, or order summary. During observation, an LPN administered medications through the PEG tube, flushed the tube before and after medication administration, but did not assess tube placement and did not check residual before giving the medications. The LPN stated the tube feeding was running, forgot to check residual, and said placement would have been verified by auscultation, which he/she believed was the correct method. The facility also failed to ensure the resident received liquid nutrition and water flushes as prescribed and failed to document and monitor the amounts provided. The resident’s orders changed over time from continuous Jevity 1.2 at 70 ml/hour for 16 hours daily with water flushes to an 8-hour nocturnal schedule with 150 ml water flushes four times daily. The MAR/TAR documented when tube feeding was initiated and removed, but the times varied and did not show the resident’s daily intake or how staff monitored whether the ordered amount of nutrition was received. The fluid intake record did not consistently document daily fluid amounts, with no actual intake documented on 17 of 30 days, and the chart contained no documentation showing how nursing staff monitored the resident’s daily liquid nutrition amounts. The tube feeding and water flush bags were also not labeled accurately according to accepted nursing standards of practice. Observations showed the nutrition and water bags hanging without documented time hung or staff initials, and the bags did not consistently reflect the current physician’s order. Staff interviews confirmed that the bags should have been labeled with the resident’s name, date, time hung, and the order, and that the nurse should document how much nutrition and water was given when the machine was turned off. The RD, unit manager, and DON all stated they expected staff to follow the tube feeding and flush orders and to document the amounts received, but the record reviewed did not show that this occurred.
Failure to Complete Monthly Medication Regimen Reviews and Follow Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews were completed and that consultant pharmacist recommendations were reviewed and followed in a timely manner for two residents. The facility policy stated that the consultant pharmacist was to perform a medication regimen review for every resident receiving medication upon admission and at least monthly thereafter, and that the review involved the resident’s medical record to identify and resolve medication problems and irregularities. Record review showed that for both residents, pharmacy recommendations were made in April and May 2025, but there was no documentation that medication regimen reviews were completed from June through October 2025. One resident was admitted with chronic pain syndrome and anxiety disorder. The consultant pharmacist issued recommendations in August and September 2025 that the resident’s Morphine Sulfate order needed a 14-day stop date and that the Lorazepam order needed a specific number of days for PRN use or discontinuation. The resident’s TAR showed those orders remained unchanged in August and September 2025. In October 2025, another recommendation was made regarding the Lorazepam order. When records were reviewed on 12/4/25, there was no documentation for the April or May 2025 recommendations, and no documentation that MRRs were completed for June or July 2025. The resident’s December 2025 order summary still showed Lorazepam and Morphine Sulfate orders that had been entered on 8/5/25, and both orders were discontinued on 12/4/25. The second resident was admitted with hypertensive heart disease and chronic kidney disease with heart failure. Pharmacy recommendations were made in April and May 2025, but there was no documentation that MRRs were completed from June through October 2025. When records were reviewed on 12/4/25, there was no documentation for the April or May 2025 recommendations and no documentation that MRRs were completed for June, July, or August 2025. Staff interviews identified that the wound nurse and unit managers were responsible for the MRR process, that the facility had changed pharmacies around June 2025, and that there were inconsistencies in how recommendations were received and followed. The DON stated there was no back-up system to ensure all MRRs were completed when the pharmacy changed.
Failure to Provide Ordered Breakfast Items on Room Trays
Penalty
Summary
The facility failed to provide a choice of food for three days for one resident who received room trays. The resident had Parkinson's disease without dyskinesia or fluctuations, was cognitively intact, dependent on a wheelchair for mobility, and independent for upper body motions. The facility's Food and Nutrition Services Policy stated that residents should receive a nourishing, palatable, well-balanced diet that considers resident preferences, and that reasonable efforts would be made to accommodate resident choices and preferences. The resident reported on three consecutive mornings that oatmeal and milk listed on the meal ticket were not received at breakfast, and said this happened frequently. On each of those mornings, the meal ticket observed by surveyors showed oatmeal and milk were listed to be served. The resident said he or she had told nursing staff but still did not receive the items, and had begun circling the items on the meal ticket so staff could see what was missing. Staff interviews showed the Dietary Manager said room-tray residents could not order ahead because the facility was in the process of getting new food software, and residents were expected to tell tray passers if they needed something. A CNA and an LPN said residents could request missing or different items, and the DON said CNAs were supposed to double check meal tickets and notify the kitchen if a resident did not receive something or wanted a change.
Failure to Notify Physician of Medication Refusal and Delayed Insulin Administration
Penalty
Summary
The facility failed to notify a resident's physician of the resident's refusal of dialysis medication and the late administration of sliding scale insulin. The resident, who had diagnoses of end stage renal disease, dependence on renal dialysis, and diabetes, was prescribed Sevelamer to be taken with meals and insulin Lispro per sliding scale. On the day in question, the resident refused Sevelamer at breakfast and was not offered the medication at lunch, yet the Certified Medication Technician (CMT) documented that the medication was given at both meals. The CMT did not inform the charge nurse of the refusal or omission, despite knowing the importance of the medication and the requirement to report such incidents. Additionally, the Agency Registered Nurse (RN) did not perform the resident's lunch time blood glucose monitoring or administer the sliding scale insulin after lunch, and did not communicate this to anyone. The Medication Administration Record (MAR) indicated that the insulin was administered later in the afternoon, but there was no documentation that the physician had been notified of the delay. Interviews with facility staff, including the Nurse Unit Manager and Director of Nursing, confirmed that the physician was not notified of the missed or refused medications, and that proper documentation and communication protocols were not followed.
Failure to Document and Communicate Medication Refusals and Omissions
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, diabetes, and dependence on dialysis did not receive medications and treatments as ordered, and staff failed to document and communicate these omissions and refusals appropriately. The resident reported not receiving required medications, including Sevelamer and insulin, after meals. Staff interviews revealed that a Certified Medication Technician (CMT) did not offer the Sevelamer at lunch after the resident refused it at breakfast, and incorrectly documented that the medication was administered at both meals. The CMT also failed to inform the charge nurse or unit manager about the resident's refusal and the omission of the medication. Additionally, the resident did not receive blood glucose monitoring or sliding scale insulin after lunch as ordered, due to the assigned nurse being occupied with other care tasks. The nurse did not communicate this missed care to management. The resident's care plan was not updated to address the ongoing refusal of medications, as the care plan coordinator was unaware of the issue. The facility's policies on insulin administration and medication administration did not address sliding scale insulin, and staff did not follow procedures for timely administration and accurate documentation. Facility leadership, including the unit nurse manager and Director of Nursing, confirmed that refusals and omissions should have been documented correctly and communicated to management, and that the resident's care plan should have addressed medication refusals. The Medication Administration Record (MAR) showed inaccurate documentation, and the timing of insulin administration was not consistent with policy or physician orders.
Failure to Ensure Communication and Coordination for Dialysis Care
Penalty
Summary
The facility failed to ensure effective communication and coordination between the facility and the dialysis provider for a resident with end stage renal disease who required regular dialysis treatments. According to the facility's own policy, the resident's care plan should reflect dialysis needs and there should be ongoing communication between the dialysis clinic and the facility. However, for approximately two months, there was no written or verbal communication between the facility and the dialysis provider regarding the resident's dialysis treatments. The dialysis clinic nurse confirmed that the facility had not provided a form for reporting, nor had they called to obtain verbal updates. Similarly, facility staff acknowledged that written communication from the dialysis clinic had ceased for at least four weeks, and no efforts were made to reestablish this communication or request reports from the dialysis provider. The resident, who had diagnoses of end stage renal disease and dependence on renal dialysis, reported that while facility nurses initially placed a form with vital signs and weight in a bag on the wheelchair, dialysis nurses stopped retrieving the form and the resident eventually stopped reminding them. The resident also stated that no information was provided back to the facility after dialysis treatments for a significant period. The Director of Nursing stated that it was expected for licensed nurses to send and receive written reports for each dialysis appointment, but this process was not followed, resulting in a lack of coordinated and consistent care for the resident.
Failure to Follow Infection Control Protocols During Central Line Dressing Change
Penalty
Summary
A deficiency occurred when a nurse failed to follow established infection prevention and control protocols during a central venous catheter (CVC) dressing change for a resident with end stage renal disease requiring hemodialysis. The nurse entered the resident's room without donning a gown or mask, placed a prepackaged dressing on a surface without using a barrier, and after hand hygiene and gloving, applied an adhesive dressing over the resident's dialysis access site without first cleansing the site. The nurse also did not provide a mask for the resident, as required by facility policy and the contents of the central line dressing kit. Facility policies and recent CMS guidance require the use of enhanced barrier precautions (EBP), including gown and glove use, and the cleansing of the catheter insertion site with an approved antiseptic solution prior to dressing application. The nurse did not follow these protocols, and the Director of Nursing confirmed that the expected procedures were not adhered to, including the use of appropriate PPE, site cleansing, and supply barriers. The resident's care plan and physician orders specified regular and as-needed dressing changes for infection prevention, but the observed dressing change did not meet these standards.
Failure to Provide Dialysis Services Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis three times a week received the necessary physician-ordered dialysis services on two occasions. The resident, who was severely cognitively impaired and diagnosed with end-stage renal disease (ESRD), missed dialysis appointments on two separate days due to a lack of transportation arrangements. This oversight led to the resident experiencing significant health issues, including weight gain, abdominal pain, acute encephalitis, hyponatremia, hyperkalemia, and low hemoglobin levels, which necessitated an immediate blood transfusion before dialysis could be administered. The deficiency was primarily due to a breakdown in communication and responsibility among the facility's staff. The Admissions Director, who was new to the position, was unaware of the responsibility to arrange transportation for the resident's dialysis appointments. Additionally, the charge nurse and other staff members failed to notify the appropriate personnel or the resident's family about the missed dialysis sessions. This lack of communication and coordination resulted in the resident not receiving dialysis for six days, ultimately leading to hospitalization. Interviews with various staff members, including LPNs, the Unit Manager, and the Director of Nursing, revealed that there was a general lack of awareness and follow-through regarding the resident's dialysis schedule and transportation needs. The facility's policies on care coordination and transportation were not effectively implemented, contributing to the resident's missed dialysis treatments and subsequent health decline. The deficiency was identified as an immediate jeopardy situation, indicating a severe risk to the resident's health and safety.
Failure to Notify of Missed Dialysis and Fall
Penalty
Summary
The facility failed to ensure proper communication and coordination of care for a resident with End-Stage Renal Disease (ESRD) who missed dialysis appointments on two occasions. The resident, who was severely cognitively impaired and dependent on renal dialysis, missed dialysis on two separate days due to transportation issues. Despite the facility's policy requiring prompt notification of significant changes in a resident's condition, the staff did not notify the physician, family, or department heads about the missed dialysis sessions until several days later. Additionally, the resident experienced a fall, which was unwitnessed, and the facility staff failed to notify the necessary parties, including the physician and family, in a timely manner. The fall was reported to the Director of Nursing (DON) and family member, but not until after the incident occurred. The resident's medical record showed no documentation of notification to the physician or family about the missed dialysis or the fall until much later, which was a significant oversight in communication and care coordination. The lack of timely communication and coordination resulted in the resident being hospitalized due to elevated potassium and low hemoglobin levels. Interviews with facility staff, including the DON, Nurse Practitioner, and Medical Director, revealed that they were not informed of the missed dialysis sessions or the fall until after the resident's condition had deteriorated. The facility's failure to adhere to its Coordination of Care Policy and ensure effective communication among staff and with external parties contributed to the resident's hospitalization.
Facility Fails to Maintain Cleanliness and Proper Labeling in Kitchen
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the kitchen, as observed during the survey. There was a buildup of grime under the dishwasher, a small leak from the garbage disposal, grime and debris including cups and dust under the ice machine, and grime around the nozzles of the juice machine. Additionally, the light fixtures above the steam table were dusty. Dietary Aide A's hair was not fully covered by a hair restraint, and the temperature of the milk in the 400 Hall kitchenette was measured at 48.3°F, which is above the required 41°F or colder. The Dietary Aide was unaware that their hair was not fully covered, and another Dietary Aide admitted to not checking the milk temperature prior to that day. The Dietary Manager acknowledged the issues with the garbage disposal and the lack of labeling for certain substances, including sugar and an unidentified liquid in a bottle above the stove, which was later identified as water. The observations and interviews revealed that the facility did not adhere to professional standards for food storage, preparation, and distribution. The Dietary Manager and Maintenance Director had attempted to address some of the issues, such as the garbage disposal leak, but the problems persisted. The lack of proper labeling and temperature control, along with inadequate hygiene practices, potentially affected all 105 residents in the facility.
Failure to Maintain Commode Risers and Mechanical Lifts
Penalty
Summary
The facility failed to maintain the commode risers in resident rooms in an easily cleanable condition and did not ensure that mechanical lifts on the 300 and 400 Halls were in sound condition. Observations revealed that the commode riser in one resident's room was not easily cleanable, and another had a crack. The Maintenance Director admitted to checking the commode risers monthly but did not document these checks, and CNAs were also expected to check the risers but did not do so effectively. This issue potentially affected two residents who used commode risers. Additionally, the facility did not maintain six mechanical lifts in sound condition, with observations showing that the mast of the lifts on the 400 Hall was very loose. Multiple staff members, including CNAs and a Restorative Aide, used the lifts but did not notice the looseness. The DON stated that staff should notify the Maintenance Director of any mechanical issues, place a sign on the lift indicating it should not be used, and move the lift to the service hall. This deficiency potentially affected 12 residents who depended on mechanical lifts for transfers.
Failure to Properly Assess and Monitor Medication Administration
Penalty
Summary
The facility failed to observe a resident while taking medications and left medications on the resident's bedside table without proper assessment or physician's order. Resident #88, who had been at the facility for about one and a half years, was found with a medication cup containing more than four pills on their overbed tray. The resident reported that staff frequently left medications for them to take later. The resident's medical records showed no assessment or physician's order for self-administration or bedside storage of medication, and staff interviews confirmed that medications should not be left at the bedside without proper authorization and assessment. Additionally, the facility failed to assess two other residents, Resident #6 and Resident #71, for their ability to self-administer medications. Both residents had severe cognitive impairments and were not capable of safely self-administering medications. Despite this, there were orders in their records allowing them to keep over-the-counter (OTC) medications at their bedside. Staff interviews revealed that these orders were likely clicked by mistake in the electronic medical record system, and neither resident was appropriate for self-administration of medications. The Director of Nursing (DON) and other staff members acknowledged that an assessment should be conducted before allowing any resident to self-administer medications. The facility's policies required an interdisciplinary team to assess the resident's cognitive, physical, and visual abilities, and a physician's order was necessary for self-administration. However, these procedures were not followed for the residents in question, leading to the deficiencies noted in the report.
Failure to Ensure Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that pureed eggs were prepared in a palatable manner and that hot foods on room trays were maintained at a safe and appetizing temperature during the breakfast meal. Observations revealed that the Dietary Manager (DM) did not follow a recipe or add any seasonings to the pureed eggs, resulting in a lack of flavor. The DM admitted to not consulting the Registered Dietitian (RD) for flavor enhancements and had not tasted the pureed eggs before serving them. The RD confirmed that they had not regularly tasted pureed products and did not consume eggs or dairy products themselves, leading to a lack of oversight in the preparation of pureed foods. Additionally, multiple residents reported that their food was consistently served cold. Observations showed that room trays were delivered over an extended period, causing the food to cool down significantly. Temperature checks of the food on the trays confirmed that the food was not at the appropriate temperature, with sausage and scrambled eggs measuring below the recommended 120 F. Interviews with Certified Nursing Assistants (CNAs) and the DM indicated that there was no regular practice of checking the temperatures of room trays, and the RD had not been involved in this process for some time. Several residents, including those with cognitive impairments, expressed dissatisfaction with the temperature of their meals, stating that the food was often cold by the time it reached their rooms. The facility's failure to maintain appropriate food temperatures and ensure the palatability of pureed foods affected the residents' dining experience and overall satisfaction with their meals.
Failure to Label and Monitor Food in Resident Use Refrigerator
Penalty
Summary
The facility failed to ensure that food in the resident use refrigerator was labeled with the resident's name and the date the food item was brought in, as per the facility's policy. During an observation, several items including salad dressings, mayonnaise, coffee creamer, relish, restaurant sauce, and dietary supplements were found without proper labeling. Additionally, three containers of unidentified food, one cup of an unidentified item, and a bag of corn dogs were also not labeled. This practice potentially affected an unknown number of residents who have foods brought in by visitors, with the facility census being 105 residents. Interviews with staff revealed that the refrigerator should be cleaned twice per week, and all items should be labeled with the resident's name and the date they were brought in. However, the Housekeeping Supervisor and a housekeeper admitted that the refrigerator had not been cleaned recently, and the 300 Hall Unit Manager had previously notified housekeeping employees to clean the refrigerator. The lack of proper labeling and regular cleaning led to the presence of expired and unidentified food items in the resident use refrigerator, which is a violation of the facility's policy on safe food handling for food brought in from outside sources.
Failure to Ensure Proper Hand Hygiene and Infection Control
Penalty
Summary
The facility failed to ensure proper hand hygiene, use of barriers for supplies, and cleansing of the glucometer during blood glucose monitoring and insulin administration for three sampled residents. The facility's policies on hand hygiene and blood glucose monitoring were not followed by the staff, leading to multiple instances of non-compliance. Specifically, the staff did not sanitize their hands before and after resident care, did not use barriers for supplies, and did not properly sanitize the glucometer between uses. For Resident #68, the RN did not sanitize their hands before entering the resident's room, placed a storage tray on the resident's bed without a barrier, and did not sanitize their hands before and after using gloves. The RN also failed to properly clean the glucometer and did not follow the correct procedure for insulin administration. Similar deficiencies were observed for Resident #91, where the RN did not sanitize their hands, did not use a barrier for supplies, and did not wait the required time after sanitizing the glucometer before using it again. Resident #39 also experienced similar issues, where the RN did not sanitize their hands before and after care, did not use a barrier for supplies, and did not properly document the resident's blood glucose levels. The RN admitted to not following the proper procedures due to being hurried and nervous. The facility's DON and Unit Manager confirmed the expectations for hand hygiene and infection control, but the staff failed to adhere to these protocols during the observed incidents.
Failure to Complete PASARR Screening in a Timely Manner
Penalty
Summary
The facility failed to ensure a resident with a major mental illness diagnosis had a required DA-124C/Level I Preadmission Screening and Resident Review (PASARR) completed in a timely manner. Resident #65, who was admitted with diagnoses including PTSD, depression, adjustment disorder with anxiety, and insomnia, did not have the PASARR Level I completed until several months after admission. The social worker responsible for the PASARR screenings admitted to not realizing that the screening was required for private pay residents as well as Medicaid residents until much later. The Director of Nursing confirmed that the facility's policy required the PASARR Level I to be completed for all residents regardless of payment method and that it should be done prior to or upon admission. The oversight was identified during a review of the resident's records, which showed the PASARR Level I was only completed on 5/1/24, despite the resident being readmitted on an earlier date. This delay in completing the required screening could have impacted the care planning and services provided to the resident.
Failure to Provide Comprehensive Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program based on a comprehensive assessment and care plan of each resident's interests, hobbies, and abilities for two sampled residents. Resident #7, who was receiving hospice care and had multiple diagnoses including dementia, anxiety disorder, and depression, was observed to spend most of his/her time in his/her room or in the living room area with the television on. Despite having a care plan that emphasized the importance of activities such as live music, pet visits, and religious activities, the resident's participation in these activities was minimal. The resident often expressed dissatisfaction with the television programming and lacked a remote control to change channels, leading to a lack of engagement in meaningful activities. Resident #44, also receiving hospice care and diagnosed with dementia, anxiety disorder, and depression, was similarly observed to spend most of his/her time in the living room area or in bed, not engaged in any activities. The resident's care plan included goals for positive responses to activities such as pet visits, snacks, and live music, but the resident's participation in these activities was limited. Observations showed the resident often sitting in the living room area with his/her head down or asleep, indicating a lack of engagement in the planned activities. Interviews with the Activities Director and other staff revealed that the facility had issues with staffing and time management, which impacted their ability to provide adequate activities for all residents. The Activities Director mentioned that they could do more for the residents if they had additional staff. The facility's transition to a new electronic health records system also contributed to difficulties in tracking residents' participation in activities. Overall, the facility's failure to implement a comprehensive and individualized activity program led to the deficiency observed by the surveyors.
Failure to Implement Timely Fall Prevention Interventions and Use Gait Belt
Penalty
Summary
The facility 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. Resident #6, who had multiple diagnoses including multiple sclerosis and a history of falling, experienced a fall on 2/17/24. The immediate intervention was to lower the resident's bed and evaluate toileting needs, but these interventions were not documented in the care plan. The resident fell again on 4/9/24, resulting in a hematoma on the forehead and a hospital visit. The care plan was updated only on 4/28/24 to include keeping the bed in a low position and monitoring for changes in condition, indicating a delay in implementing necessary interventions after the initial fall in February. The facility also failed to ensure staff utilized a gait belt for Resident #226, who required assistance with transfers. On 5/2/24, a CNA assisted the resident in transferring from bed to wheelchair without using a gait belt, despite the resident's need for maximal assistance and a history of falls. The CNA admitted to not using the gait belt because it was the first time meeting the resident and the resident felt sick. Other staff interviews confirmed that gait belts should always be used for residents requiring assistance with transfers, but this protocol was not followed in this instance. The Director of Nursing (DON) acknowledged that the Unit Manager was responsible for fall investigations and should have ensured that interventions were added to the care plan. The DON also confirmed that staff should always use a gait belt when assisting residents with transfers. The failure to promptly update care plans with fall prevention interventions and the improper transfer technique without a gait belt contributed to the deficiencies identified in the report.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received ongoing assessments of the dialysis site and accurate documentation of the dialysis site. The resident, diagnosed with End-Stage Renal Disease (ESRD) and dependent on renal dialysis, had no documented orders for dialysis treatments, site care, or frequency of site assessments. The resident's baseline care plan and progress notes lacked specific details about the dialysis access type and schedule. Observations confirmed the presence of a dialysis catheter, but there was no consistent documentation or assessment of the site by the nursing staff. Interviews with the resident and nursing staff revealed that the dialysis site was not regularly assessed, and there were no documented assessments in the computer system. The Director of Nursing (DON) confirmed that it was expected for nurses to know the type of dialysis access, assess the site every shift, and document these assessments. However, due to the absence of a unit manager and lack of proper documentation, it was assumed that the necessary assessments were not performed. The facility also lacked a specific policy for dialysis care, further contributing to the deficiency in care for the resident requiring dialysis.
Failure to Implement Comprehensive PTSD Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive PTSD care plan was in place and that staff were educated on ways to decrease a resident's exposure to triggers and manage the effects of a trigger. Resident #65, who was diagnosed with PTSD, did not have a specific care plan addressing his/her PTSD needs. The existing care plan lacked detailed information on the resident's trauma history, typical reactions to triggers, and comprehensive guidance for staff on how to decrease exposure to triggers and manage the effects of a trigger. The resident identified loud noises, war and violent movies, the 4th of July, and certain conversations as triggers, but this information was not adequately reflected in the care plan or communicated to the staff. Interviews with staff revealed a lack of awareness and training regarding the resident's PTSD and specific triggers. A CNA and an LPN both indicated they were unaware of the resident's PTSD diagnosis, the resident's trauma history, or how to identify and manage triggers. The Director of Nurses acknowledged that the PTSD care plan should include all known triggers, strategies to decrease the likelihood of a trigger, and actions to take if the resident was triggered, but this was not implemented. This deficiency highlights a significant gap in the facility's trauma-informed care process and staff education on managing PTSD in residents.
Failure to Consider Alternatives Before Installing Bed Rails
Penalty
Summary
The facility failed to ensure that all appropriate alternatives were considered before installing bed rails for a resident with a history of falling from bed. The resident, who had multiple diagnoses including Multiple Sclerosis, dementia, muscle weakness, and a history of falls, was assessed for bed rail use only after the family insisted on it following two falls. The facility's Bed Entrapment Prevention policy stated that bed rails were to be used only by rare exception and after proper assessment, but the documentation showed that other alternatives were not thoroughly explored or justified before resorting to bed rails. The resident's care plan included interventions such as a lowered bed and frequent rounds, but these were not consistently documented or followed. After the resident's falls, the family requested bed rails, and the facility installed them despite their policy against using bed rails as restraints. The Bed Rail Observation/Assessment form indicated that the family was educated about the risks and benefits, but there was no documentation of other devices being attempted or why they were deemed inappropriate. The facility's staff, including the Director of Nursing and the Director of Rehabilitation, confirmed that the bed rails were installed primarily due to the family's insistence and not as a fall precaution intervention. Interviews with staff revealed that the resident had previously used bed canes for repositioning and that other interventions like a parameter mattress or a larger bed were not considered. The facility's documentation and staff interviews indicated a lack of thorough assessment and exploration of alternatives before installing the bed rails, leading to a deficiency in ensuring resident safety and compliance with the facility's policies.
Failure to Ensure Bed Rail Safety
Penalty
Summary
The facility failed to ensure that bed rails for one resident were compatible with the bed and were installed and maintained safely. Resident #6, who had multiple diagnoses including multiple sclerosis, dementia, muscle weakness, and a history of falling, had bed rails that were not properly secured. The bed rail's Zone Six measured seven and one-half inches, which was outside the facility's safety guidelines of less than two and three-eighths inches or over twelve and one-half inches. Additionally, the bed rail had a metal lever that could cause the rail to fall quickly and with force, and the adjustable tightening knob was found to be loose, allowing the rail to move and change spacing, posing a risk for entrapment and not providing adequate support for repositioning the resident in bed. The facility's Bed Entrapment Prevention Policy aimed to improve bed safety and mitigate the risk of entrapment, with specific guidelines for testing bed rails across all seven potential zones of entrapment. Despite this, the Maintenance Supervisor, who was responsible for installing and ensuring the safety of the bed rails, did not perform audits on bed rail safety and relied on nursing staff to report any issues. The Director of Nursing (DON) acknowledged that the bed rail was not safe and that nursing staff should observe the bed rails each shift and report any instability or unsafe spacing to the Maintenance Supervisor. Interviews with staff revealed that the bed rails had been installed in April, and no problems had been reported by staff. However, observations showed that the bed rail was loose and could be easily adjusted, which compromised its safety. The DON and Maintenance Supervisor both confirmed that the bed rail was not installed correctly and that staff might have loosened the bars, indicating a need for better staff education on bed rail safety. The facility's failure to ensure the bed rails were compatible with the bed and maintained safely led to a significant risk of entrapment and injury for Resident #6.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 799 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Independence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunterra Springs Independence | 0.5 mi | ★★★★★ | 0 | 0 |
| Monterey Park Rehabilitation & Health Care Center | 0.8 mi | ★★★★★ | 13 | 0 |
| Ignite Medical Resort Blue Springs | 1 mi | ★★★★★ | 0 | 0 |
| Abode Health And Wellness Center | 2.5 mi | ★★★★★ | 6 | 0 |
| Rehabilitation Center Of Independence, The | 2.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Jackson Creek Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.