Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jackson County Medical Care Facility during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment, care planned as a high fall risk requiring two staff for transfers with a stand-up mechanical lift, was transferred by a single CNA who did not review the care plan or Kardex and used a lift she knew had a missing clip. During the bed-to-wheelchair transfer, a buckle/strap on the lift came apart, the resident fell to the floor, and imaging confirmed a right humerus fracture. Staff interviews showed that nurses knew the resident required a two-person transfer, the CNA believed the resident was a one-person transfer based on routine practice, and maintenance later found and replaced missing clips on several lifts without having received prior reports or work orders about the defects. The facility’s internal investigation attributed the event to sling malfunction and did not address the failure to use two staff as required by the resident’s care plan.
The facility failed to maintain resident dignity when an LPN was observed having a personal phone conversation on speaker while preparing medications, including insulin, at a medication cart. Two residents were present during this incident, one waiting for her medications and the other seated nearby. The Nursing Unit Manager confirmed that phone use is prohibited in care areas, aligning with the facility's cellphone use policy.
A facility failed to ensure accurate advance directive documentation for a resident with serious health conditions. The resident's medical record contained a DNR order without a completed DO-NOT-RESUSCITATE ORDER document, which was found unsigned in the physician's folder. Interviews revealed a breakdown in the process of completing and documenting advance directives, as the document was not signed by the physician before the DNR order was entered into the medical record.
The facility failed to transmit MDS assessments to CMS in a timely manner for three residents. One resident's 5-day MDS was not transmitted by the due date, while another's entry MDS remained in Export Ready status past the due date, and their 5-day MDS was overdue. Additionally, a comprehensive assessment for this resident had not been started. A third resident's admission MDS had an incorrect submit by date. These actions did not comply with RAI guidelines.
A facility failed to complete a PAS/ARR for a resident after a 30-day exemption period. The resident, admitted with major depression and prescribed anti-depressants, had no further screenings or documentation submitted to the State Mental Health Authority. Despite changes in psychotropic medication and a new anxiety diagnosis, required documentation was missing. The Case Manager/Social Service Director confirmed the oversight but could not explain the lapse.
The facility failed to develop comprehensive care plans for two residents, one with atrial fibrillation on Eliquis and another with end-stage renal disease on dialysis. The absence of care plans for these high-risk conditions was confirmed by the DON and nursing staff, highlighting deficiencies in care management.
A resident with moderately impaired cognition and dependent on staff for personal hygiene was observed with an unkempt beard despite expressing a preference to be shaved. Facility documentation indicated the resident required assistance, but staff interviews revealed inconsistencies in understanding and providing for the resident's preferences, contrary to facility policies.
A resident with Alzheimer's and major depressive disorder was admitted with adequate hearing using hearing aids, but the facility failed to document or provide these devices. Observations and interviews revealed the resident had been without hearing aids for an extended period, affecting her ability to hear and communicate. Staff and family were aware of the issue, but there was no documentation or timely investigation, leading to unmet needs.
A facility failed to justify the continued use of psychotropic medications for a resident who was observed to be pleasant and socially engaging without distressing behaviors. Despite the absence of documented mood concerns, the facility continued the use of Seroquel without adequate justification or documentation of a gradual dose reduction. The resident's psychiatric condition remained unchanged, and the facility did not provide the necessary documentation to support the continued medication use.
Neglect During Mechanical Lift Transfer Resulting in Fractured Humerus
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not following the resident’s care plan and by using defective equipment during a transfer, resulting in a fall and a fractured right humerus. The resident was an elderly female with dementia and severe cognitive impairment, assessed as high risk for falls. Her comprehensive care plan and Kardex in place at the time specified that she required two staff for transfers using a stand-up mechanical lift. Despite this, on the morning of 12/26/25, a CNA transferred the resident alone from bed to wheelchair using the stand-up lift. During the transfer, the CNA reported hearing a pop sound as the clasp unbuckled and the right strap came off the lift, causing the resident to fall to the floor and complain of right upper extremity pain with visible swelling. A stat x-ray later confirmed a fracture of the surgical neck of the humerus with greater tuberosity extension. The CNA stated she was new, believed the resident to be a one-person transfer based on prior practice, and admitted she did not review the care plan or Kardex because she only checked the Kardex for new residents. She also reported that one of the clips on the right side of the lift was missing, that she had noticed this on a prior date, and that she had used the same lift with the missing clip previously without incident. Interviews and observations further documented that the stand-up lift used in the incident had differing clip types on each side and that maintenance later found several lifts with missing clips/stoppers and replaced them, with no prior work orders or reports about missing clips before the fall. Nursing staff, including the unit manager who conducted the investigation, were aware that the resident was care planned as a two-person transfer with the stand-up lift, but the internal investigation focused on sling buckle malfunction and did not address the use of only one staff member for the transfer. Post-fall assessments by nursing staff and the MDS nurse confirmed that the resident sustained a fracture and experienced a significant change in condition, including increased dependence in ADLs and changes in transfer status, directly associated with the fall during the improperly conducted transfer.
Failure to Maintain Resident Dignity During Medication Preparation
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as observed in the case of two residents. During a medication preparation session, an LPN was observed engaging in a personal phone conversation on speaker while preparing medications, including insulin, at a medication cart. One resident was waiting next to the cart for her medications, while another resident was seated nearby. The LPN abruptly ended the phone conversation after a few minutes. The Nursing Unit Manager later confirmed that staff should not use phones in care areas, particularly during medication preparation. The facility's cellphone use policy, last reviewed in September 2024, prohibits personal device use in resident rooms or while providing direct care, limiting it to designated break areas.
Failure to Ensure Accurate Advance Directive Documentation
Penalty
Summary
The facility failed to ensure accurate advance directive information was in place for a resident admitted with multiple serious health conditions, including end-stage renal disease and congestive heart failure. The resident's medical record showed a physician order for a Do Not Resuscitate (DNR) status, but the corresponding DO-NOT-RESUSCITATE ORDER document was missing from the medical record. The document was later found in the physician's folder, unsigned by the physician, indicating that the DNR order was prematurely entered into the medical record without the necessary completion of the advance directive process. Interviews with facility staff, including the Unit Manager, Social Worker, and Director of Nursing, revealed a breakdown in the process of completing and documenting advance directives. The Social Worker was responsible for discussing and completing the DO-NOT-RESUSCITATE ORDER with the resident, obtaining necessary signatures, and ensuring the document was signed by the physician before being scanned into the medical record. However, the document was not signed by the physician, and the DNR order was entered into the medical record without the completed document, highlighting a failure in the facility's protocol for handling advance directives.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely transmission of Minimum Data Set (MDS) assessments for three residents to the Centers for Medicare & Medicaid Services (CMS) system. Resident #470 had an entry MDS transmitted and accepted, but the 5-day MDS completed on 1/20/2025 was not transmitted by the due date of 1/21/2025. Additionally, the admission MDS was ready for export on 1/20/2025 but had not been completed or transmitted by the review date of 1/24/2025. Resident #472's entry MDS was due on 1/10/2025 but remained in Export Ready status as of 1/23/2025, with the actual completion date noted as 1/17/2025. The 5-day MDS for this resident was in progress and overdue by six days as of 1/23/2025. Furthermore, a comprehensive assessment due by 1/23/2025 had not been started. Resident #477's admission MDS was completed on 1/23/2025, but the submit by date was incorrectly noted as 2/6/2025, instead of the correct date of 1/23/2025. These deficiencies indicate a failure to adhere to the Resident Assessment Instrument (RAI) guidelines, which require timely completion and transmission of assessments.
Failure to Complete PAS/ARR After 30-Day Exemption
Penalty
Summary
The facility failed to ensure that a Preadmission/Annual Resident Review (PAS/ARR) was completed for a resident after the 30-day exemption period. The resident was admitted with a diagnosis of major depression and was prescribed an anti-depressant medication. Initially, the resident was placed on a 30-day exemption with the expectation of discharge within that period. However, no further Level I or Level II screenings were conducted, and there was no documentation indicating that the State Mental Health Authority was informed of the resident's continued stay at the facility. Additionally, there was no documentation regarding the resident's need for a Level II assessment from Community Mental Health. The resident's clinical record showed changes in psychotropic medication and a new diagnosis of anxiety, which were not followed by the required PAS/ARR documentation. During an interview, the Case Manager/Social Service Director confirmed that the social workers were responsible for tracking PAS/ARR due dates and notifying him for completion and submission to Community Mental Health. Upon review, it was confirmed that there was no information in the Community Mental Health portal, and the Case Manager/Social Service Director could not provide an explanation for the missing documentation.
Deficiencies in Care Plan Development for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care management. Resident #92, who was admitted with a diagnosis of atrial fibrillation and prescribed Eliquis, a blood-thinning medication, did not have a care plan addressing the use of this high-risk medication. This oversight was confirmed by the Director of Nursing, who acknowledged the absence of a care plan for the anticoagulant, which is expected for managing such medications. Similarly, Resident #370, who was admitted with end-stage renal disease and dependent on dialysis, lacked a care plan and physician orders related to her dialysis treatment. Despite the resident's routine attendance at outside dialysis appointments, there was no documentation in her care plan or physician orders regarding her dialysis schedule or necessary assessments. This deficiency was confirmed by both a Registered Nurse and the Nursing Unit Manager, who noted the importance of having a dialysis care plan and physician orders to ensure effective communication and assessments.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADL) for a resident, resulting in the potential for unmet needs. The resident, who was admitted with diagnoses including congestive heart failure and arthritis, was assessed to have moderately impaired cognition and was dependent on staff for personal hygiene. Despite the resident's preference to be shaved and not have a beard, observations over several days showed that the resident had a long, unkempt beard. The resident reported having communicated this preference to the staff previously. The facility's documentation, including the Kardex and task log, indicated that the resident required substantial to maximal assistance for personal hygiene tasks. Interviews with staff revealed inconsistencies in understanding the resident's preferences for shaving, with one CNA incorrectly stating that the resident preferred the beautician for shaving. The Unit Manager confirmed that the resident's preference should be documented in the Kardex and that CNAs should assist with shaving. The facility's policies on ADLs and shaving male residents emphasize providing care according to the resident's desires, which was not adhered to in this case.
Failure to Provide Hearing Aids for Resident
Penalty
Summary
The facility failed to provide proper assistive devices to maintain hearing for a resident diagnosed with Alzheimer's disease and major depressive disorder. The resident was admitted with adequate hearing when using hearing aids, as noted in the Minimum Data Set (MDS) assessment. However, the facility's Kardex did not document the need for hearing aids. Observations and interviews revealed that the resident had been without hearing aids for an extended period, confirmed by both the resident and her roommate. The resident's ability to hear was compromised, requiring others to speak loudly and slowly for her to understand. Interviews with staff and family members indicated that the resident had previously thrown away her hearing aids, and the facility was aware of the missing devices. Despite this, there was no documentation of a missing item report, and the care plan interventions related to hearing aids had been removed without explanation. Family members expressed concern about the resident's isolation and inability to hear the television, which she enjoyed. The facility's policy on grievances and complaints was not followed, as there was confusion and a lack of timely investigation into the missing hearing aids.
Failure to Justify Continued Use of Psychotropic Medications
Penalty
Summary
The facility failed to justify the continued use of psychotropic medications for a resident, identified as Resident #154, who was observed to be pleasant and socially engaging without any documented distressing behaviors. The resident, a female with multiple diagnoses including major depressive disorder and delusional disorders, was on Seroquel and Effexor. Despite the absence of documented distressing behaviors or mood concerns, the facility continued the use of these medications without adequate justification or documentation of a gradual dose reduction (GDR) for Seroquel. The resident's medical records and psychiatric consults indicated that her psychiatric condition remained unchanged, and she appeared happy and denied depression or anxiety. However, the facility did not provide clinical documentation to support the continued use of Seroquel at 75 mg without a GDR. The psychiatric consults reviewed did not recommend a dose reduction, and the facility's behavior tracking logs showed minimal behaviors that were not distressing to the resident. The social worker reported that behaviors such as delusions, hallucinations, and agitation were documented in the facility's electronic medical records and reviewed quarterly. However, there was uncertainty about whether these behaviors were documented following the September GDR. The facility failed to provide the requested documentation to justify the continued use of Seroquel without a GDR before the survey exit.
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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) |
|---|---|---|---|---|
| Regency At Jackson | 0.4 mi | — | 17 | 1 |
| Vista Grande Villa | 2.1 mi | — | 18 | 0 |
| Mission Point Health Campus Of Jackson | 2.8 mi | — | 1 | 0 |
| Cascade Senior Care Center | 2.9 mi | — | 7 | 0 |
| Faith Haven Senior Care Centre | 5.2 mi | — | 13 | 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 August 2026) and official state health department websites.