Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 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.
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.
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.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near 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 | — | 3 | 0 |
| Rehabilitation Center Of Independence, The | 2.9 mi | — | 1 | 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.