Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Manor during CMS and state inspections, most recent first.
A facility failed to provide written transfer/discharge notices to residents' representatives for multiple hospital transfers and did not document the bed hold rate or reason for transfer. Records for four residents showed missing written notification at the time of transfer, and one resident had several hospital transfers with the same documentation gaps. Staff interviews confirmed nursing completed the transfer/bed hold form, but the bed hold amount was not entered and nursing did not have access to the rate information.
Failure to Follow Physician Orders: The facility did not obtain and follow physician orders for multiple residents. One resident with ESRD and a UTI had missed IV antibiotic doses and an IV issue during administration. Other residents with significant neurologic and respiratory conditions had missed ordered weekly weights, and another resident with dementia and Alzheimer's disease had repeated missed pulse oximetry documentation. The report states staff were expected to follow physician orders as ordered.
Failure to provide scheduled bathing and grooming assistance for two residents. One resident with dementia, stroke, DM2, and dependence for personal care missed most scheduled showers and was observed with dirty, unkempt hair. Another resident with CHF, dementia, DM2, and depression also missed multiple scheduled showers, had limited documentation of reattempts after refusals, and was observed with long, unkempt, oily hair and a musty odor. The DON and Administrator stated residents would be offered and/or assisted with showers at least twice weekly.
Failure to change and date oxygen tubing and the humidifier bottle per orders affected a resident with chronic respiratory failure with hypoxia and dependence on supplemental O2. The resident was ordered continuous O2 at 3 L via NC, weekly tubing and storage bag changes, and weekly humidifier bottle/tubing/water changes, but observations showed tubing and the humidifier canister labeled with an older date and the canister empty. The resident reported staff changed the tubing but not on a known schedule and that the humidifier sometimes ran out of water; RN C and the DON stated the tubing should be labeled when changed and documented on the MAR.
The facility failed to follow infection control practices during g-tube care, blood sugar checks, insulin administration, and catheter drainage bag handling. An LPN provided g-tube care for a resident on EBP without wearing a gown, a CMT checked blood sugar and gave insulin to one resident without gloves, and gave insulin to another resident without hand hygiene or gloves. A resident's urinary catheter drainage bag was also observed hanging on a wheelchair and touching the wheel during transport and while seated.
The facility failed to provide food at safe and appetizing temperatures for several residents, as observed through interviews and temperature checks. Residents reported consistently receiving cold meals, whether dining in their rooms or the dining room. The facility lacked a food temperature policy, and although a hot cart was purchased to address complaints, it had not been used yet.
The facility failed to maintain a safe, clean, and homelike environment, affecting residents and potentially impacting all. Observations revealed stains, scrapes, missing veneer, loose cables, and exposed wires, with residents expressing dissatisfaction. Staff confirmed expectations for maintenance, but no environmental policy was provided.
The facility failed to provide timely written notification to two residents and their representatives regarding hospital transfers, and did not notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for two residents, with no documentation of written notifications or notices to the Ombudsman. The Administrator and Regional Director of Operations acknowledged the expectation for notifications to be sent per regulation.
The facility failed to provide written information about the bed hold policy to two residents or their representatives at the time of hospital transfer, as required by state and federal guidelines. This deficiency was identified through record reviews and staff interviews, revealing a lack of documentation for the required notifications.
The facility failed to provide scheduled showers for four residents, leading to a deficiency in care. A resident with quadriplegia missed multiple shower opportunities, resulting in unkempt hair. Another resident with Parkinson's and dementia also missed showers, citing understaffing as a reason. A third resident with moderate cognitive impairment reported not having a shower for two weeks, and a fourth resident with multiple diagnoses received fewer showers than scheduled. Staff interviews confirmed the expectation of two showers per week.
The facility failed to maintain proper infection control practices during insulin administration and incontinent care, and did not document annual TB screenings for three residents. A CNA did not change gloves or wash hands during incontinent care, while a CMT failed to clean the insulin vial and glucometer, and did not wash hands after insulin administration. Additionally, three residents lacked documentation of annual TB screenings.
The facility did not post nurse staffing data daily in a clear and accessible format. Observations revealed that the last posted data was outdated, and the ADON, covering for the absent DON, confirmed the oversight. The Administrator and regional staff acknowledged the expectation for daily postings.
The facility did not hold quarterly QAPI meetings with all required members, as the Medical Director was absent from meetings between April and June 2024. The facility's policy requires monthly meetings with specific team members, but the Medical Director's absence was noted, and a planned meeting was canceled.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative in writing of hospital transfers and discharges for four sampled residents, and the written notices did not include the bed hold rate or the reason for transfer. The facility's policies required written notice to the resident and, if known, a family member or legal representative before transfer or discharge, including the reason for transfer, the date of transfer, and the location of discharge, as well as written information about bed hold and reserve bed payment policies prior to and upon transfer. Resident #14, Resident #16, Resident #53, and Resident #85 were each transferred to the hospital and later readmitted or returned to the facility, but the records did not show that the resident's representative was informed in writing at the time of transfer. For these residents, the record also lacked documentation of the bed hold rate and the reason for transfer. Resident #85 had multiple hospital transfers on 06/17/25, 06/30/25, 07/05/25, and 07/09/25, and the record lacked written notification, bed hold rate, and reason for transfer for each of those transfers. Staff interviews showed nursing was responsible for completing the transfer/bed hold form, the BOM had bed hold amount sheets but did not see the amount listed on the form, and nursing staff stated they did not have access to bed hold rates.
Failure to Follow Physician Orders
Penalty
Summary
The facility failed to obtain and follow physician orders for four sampled residents. The report states that physician orders were not clearly documented, transcribed, or carried out as required by the facility policy, which requires complete orders, transcription to the MAR or TAR, and clarification of unclear or missing components before implementation. The Director of Nursing and Administrator stated they would expect staff to follow physician orders as ordered. For one resident with end stage renal disease and a UTI, there was an order for IV Zosyn four times daily for nine days, but no order for an IV catheter was found. The MAR and TAR showed three missed doses of Zosyn out of 15 doses, and during observation the resident had a 22 gauge IV in the right forearm with an undated clear dressing. When the RN flushed the IV and connected the Zosyn infusion, the medication leaked from the IV site and the RN stopped the infusion. For another resident with severe hypoxic ischemic encephalopathy, acute and chronic respiratory failure, depression, anxiety, seizures, and a tracheostomy, there was an order for weekly weights every Wednesday, but seven weights were not recorded out of 17 opportunities. A resident with microcephaly, dysphagia, and reduced mobility also had an order for weekly weights for tube feeding/monitoring, but three weekly weights were not recorded out of 12 opportunities. A resident with dementia, encephalopathy, hyperlipidemia, hypertension, anxiety, and Alzheimer's disease had an order to monitor pulse oximetry every day, but pulse oximetry was not documented from 06/17/25 through 07/14/25 and on multiple additional dates, totaling 56 missed opportunities out of 66.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain grooming and personal hygiene for two residents. The facility policy on Activities of Daily Living bathing stated that nursing staff will assist residents with bathing to promote cleanliness and dignity, and the resident shower schedule showed that one resident was scheduled for showers twice weekly on Tuesday and Friday while the other was scheduled twice weekly on Wednesday and Saturday. Resident #53 was admitted with diagnoses including type II diabetes mellitus, need for assistance with personal care, hypertension, anxiety disorder, depression, unspecified dementia, and cerebral infarction. The admission MDS showed severely impaired cognition, maximal assistance needed for dressing and personal hygiene, dependence for toileting, and dependence for bathing/showering. In July 2025, the resident was scheduled for nine shower opportunities but missed six, including four scheduled showers that were not received and two refusals with no evidence of reattempts. On observation on 08/21/25, the resident was lying in bed with unkempt and dirty hair. Resident #85 was admitted with congestive heart failure, unspecified dementia, type II diabetes, and depression. The admission MDS showed intact cognition, independence with dressing, toileting, and personal hygiene, and refusal of the bathing/showering assessment. From May through August 2025, the resident missed multiple scheduled showers, including several that were not received and several refusals with limited or no reattempt documentation. Observations on 08/19/25, 08/20/25, and 08/21/25 showed the resident with long, unkempt hair, and on 08/21/25 the hair appeared oily and clumped with a noticeable musty odor.
Failure to Change and Date Oxygen Tubing and Humidifier Bottle per Orders
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident #14, who had diagnoses of chronic respiratory failure with hypoxia and dependence on supplemental oxygen. The resident had physician orders for oxygen at 3 liters continuous via nasal cannula, for oxygen tubing and storage bag to be changed weekly every Sunday, and for the humidifier bottle on the oxygen concentrator, humidifier tubing, tubing, and water in the oxygen humidifier to be changed every Tuesday. The resident’s August 2025 MAR showed the oxygen tubing and storage bag were documented as changed on 08/03/25, 08/10/25, and 08/17/25, and the humidifier bottle and tubing were documented as changed on 08/05/25, 08/12/25, and 08/19/25. During observations on 08/19/25, 08/20/25, 08/21/25, and 08/22/25, the resident was seen wearing 3 liters per minute oxygen by nasal cannula with oxygen tubing labeled 08/04/25, and the oxygen humidifier canister was empty and labeled 08/04/25. The resident stated staff changed the tubing but did not know how often, and said staff were supposed to fill the humidifier canister but it ran out of water sometimes. On 08/22/25, the resident said he/she had not seen anyone change the oxygen tubing or fill the humidifier canister yet. RN C stated the night nurse was responsible for changing the tubing and filling humidifier canisters, that it should be documented on the MAR, and that tubing should be labeled with the date, time, and initials when changed. The DON stated oxygen tubing should be changed weekly, humidifier canisters filled as needed, and the tubing should be labeled with the date when changed; she also stated it should not be documented as changed if it was not done.
Infection Control Lapses During G-tube Care, Blood Sugar Checks, Insulin Administration, and Catheter Bag Handling
Penalty
Summary
The facility failed to maintain proper infection control practices during multiple resident care activities. For Resident #49, who had g-tube care performed under Enhanced Barrier Precautions (EBP), an LPN entered the room, performed hand hygiene, put on gloves, but did not wear a gown before providing g-tube care. During interview, an RN stated a gown and gloves should be worn when doing care on someone with EBP. The facility policies reviewed stated that hand hygiene should be performed before and after care and that gown and glove use is indicated for high-contact resident care activities, including enteral tube care, for residents with wounds and/or indwelling medical devices. The facility also failed to maintain infection control during blood sugar checks and insulin administration for two residents. For Resident #14, a CMT performed hand hygiene, did not put on gloves, checked the resident's blood sugar, and administered insulin. For Resident #69, the same CMT did not perform hand hygiene, did not put on gloves, and administered insulin. In addition, Resident #1's urinary catheter drainage bag was observed hanging on the wheelchair and touching or rubbing against the wheelchair wheel on multiple occasions, including while the resident was being propelled through the facility and outside to a transportation vehicle. The facility's catheter care policy did not address care of the catheter tubing or drainage bag.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide palatable, attractive food at safe and appetizing temperatures for eight out of ten sampled residents. This deficiency was identified through observations, interviews, and record reviews. Residents consistently reported that their meals were cold, regardless of whether they ate in the dining room or in their rooms. Specific temperature measurements taken during an observation of the evening meal showed that the food was served at temperatures significantly below the recommended safe levels, with a hamburger measuring 94 degrees Fahrenheit and potato wedges at 96 degrees Fahrenheit. The facility did not have a food temperature policy in place, and the Resident Council minutes indicated ongoing complaints about cold food. Interviews with residents revealed a pattern of dissatisfaction with meal temperatures, with some residents expressing that they had stopped reporting the issue to staff due to a lack of improvement. The Dietary Manager acknowledged receiving complaints about food temperatures and mentioned that a hot cart had been purchased but not yet implemented. The Administrator expected temperature logs to be maintained for every meal and had initiated a protocol for office staff to evaluate test trays daily, although these measures had not yet been fully executed.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment, affecting at least two residents and potentially impacting all residents. Observations revealed multiple deficiencies in the physical environment, including brown stains on divider curtains, scrapes and scratches on bathroom doors and trim, missing veneer on sink vanities and closet doors, and loose cables and surge protectors on the floor. Additionally, there were gaps in drywall and ceiling tiles, and exposed wires in bed control cords, which posed a potential safety hazard. Residents expressed dissatisfaction with their living conditions, citing issues such as water leaks and collapsed ceilings. Further observations noted gouges in drywall and chipped paint along hallways, as well as bent metal around dining area entrances. Interviews with facility staff, including the Administrator, Area Director of Operations, and Regional Nurse Consultant, confirmed an expectation for the facility to be maintained and repaired to prevent such deficiencies. However, the facility did not provide a policy regarding the environment, indicating a lack of formal guidelines to ensure a homelike and safe environment for residents.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding hospital transfers, as well as failing to notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for two residents out of a sample of 17, with a facility census of 68. Resident #2 was transferred to the hospital on October 16, 2023, and readmitted to the facility on an unspecified date, with no documentation of written notification to the resident or their responsible party, nor a notice to the Ombudsman. Similarly, Resident #58 was transferred to the hospital on June 7, 2024, and again on June 30, 2024, with same-day readmissions, but lacked documentation of written notifications to the resident or their representative, and no notice was given to the Ombudsman. During an interview, the Administrator and Regional Director of Operations acknowledged the expectation for notifications to be sent per regulation.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
The facility failed to inform two residents and/or their representatives in writing about the bed hold policy at the time of their transfer to the hospital. This deficiency was identified during a review of the facility's records and interviews with staff. The facility's policy, last reviewed on 11/15/22, mandates that written information regarding the bed hold policy be provided to residents or their representatives prior to hospital transfer, as required by state and federal guidelines. However, for Resident #2, who was transferred to the hospital on 10/16/23, and Resident #58, who was transferred on 06/07/24 and again on 06/30/24, there was no documentation indicating that the required written information was provided at the time of transfer. During an interview, the Administrator and Director of Operations acknowledged the expectation that bed hold papers should be sent per regulations when residents are discharged to the hospital.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for four residents, resulting in a deficiency in the care and assistance for activities of daily living. Resident #2, diagnosed with quadriplegia, was scheduled for showers on Mondays and Thursdays but missed two out of nine opportunities in June and all three opportunities in July. Observations on July 8, 2024, showed the resident with unkempt hair, and during an interview, the resident confirmed frequently missing showers. Resident #4, with diagnoses including Parkinson's disease, diabetes mellitus, and dementia, also missed scheduled showers. Despite being cognitively intact and requiring maximal assistance for bathing, the resident missed three out of nine opportunities in May, three in June, and two in July. The resident expressed a desire for more frequent showers, attributing the lack of care to facility understaffing. Observations on July 9, 2024, showed the resident with unkempt hair and inadequate clothing. Resident #18, with moderate cognitive impairment and medical conditions such as diabetes and high blood pressure, missed two out of three shower opportunities in July. The resident reported not having a shower for two weeks, and observations noted uncombed hair and a room with a noticeable odor. Resident #21, with multiple diagnoses including neuromuscular dysfunction of the bladder and heart failure, missed several scheduled showers across May, June, and July. The resident reported receiving at most one shower a week. Interviews with staff confirmed the expectation of two showers per week, with documentation required for each instance, whether given, refused, or missed.
Infection Control and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during the administration of insulin and while providing incontinent care. During an observation of incontinent care for Resident #52, a Certified Nurse Aide (CNA) did not follow proper hand hygiene protocols. The CNA used the same gloves throughout the care process, including when obtaining wipes, cleaning the resident's perineal area, and handling clean clothing and linens. The CNA also failed to wash hands after removing gloves and before exiting the resident's room. In another instance, a Certified Medication Technician (CMT) did not adhere to infection control practices during a blood glucose check and insulin administration for Resident #68. The CMT failed to wash hands after removing gloves, did not clean the insulin vial stopper before withdrawing medication, and recapped the needle after use. Additionally, the CMT did not clean the glucometer after use, which is against the facility's policy. The facility also did not provide appropriate documentation for tuberculosis (TB) testing for three residents. Resident #24, Resident #30, and Resident #42 lacked documentation of annual TB screenings for 2023 and 2024. The facility's policies require yearly TB screenings, but these were not documented in the residents' medical records.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors on a daily basis at the beginning of each shift. Observations on multiple dates showed that the facility did not post the nurse staffing data, with the last posted sheet dated several days prior. The Assistant Director of Nurses (ADON) indicated that the Director of Nurses (DON), who was responsible for filling out the daily staffing sheets, was not present during the week of the observations. The ADON, covering for the DON, stated that the staffing sheets are typically posted by the nursing station beside the activities bulletin board. The Administrator, Regional Director of Operations, and Regional Nurse Consultant acknowledged the expectation for daily staffing to be posted.
Failure to Maintain Required QAPI Meetings
Penalty
Summary
The facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility's policy, dated August 2020, mandates that the Quality Assessment and Assurance (QAA) committee meet monthly and include specific team members such as the Administrator, Director of Nursing, Medical Director/Designee, and others. However, a review of the QAPI sign-in sheets revealed that the Medical Director did not attend any meetings from April 2024 through June 2024. During interviews, the Administrator acknowledged the absence of the Medical Director from these meetings and mentioned that a planned QAPI meeting was canceled, which the Medical Director was supposed to attend.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hubble Creek | 3 mi | ★★★★★ | 10 | 0 |
| Fountainbleau Lodge | 7.2 mi | ★★★★★ | 7 | 0 |
| Heartland Care And Rehabilitation Center | 7.2 mi | ★★★★★ | 4 | 0 |
| Stonebridge Marble Hill | 8.8 mi | ★★★★★ | 7 | 0 |
| Chateau Girardeau | 8.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.