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Deficiency Records for Jackson Creek Post Acute
A list of the most recent deficiencies for Jackson Creek Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Jackson Creek Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-05-07 | 2024-06-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-07 | 2024-06-15 | N |
| Provide activities to meet all resident's needs. | Health | 2024-05-07 | 2024-06-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-05-07 | 2024-06-15 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-05-07 | 2024-06-15 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-05-07 | 2024-06-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-05-07 | 2024-06-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-07 | 2024-06-15 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-05-07 | 2024-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-07 | 2024-06-15 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-05-07 | 2024-06-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-05-07 | 2024-06-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-07 | 2024-06-15 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-05-07 | 2024-06-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-05-07 | 2024-06-15 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-05-07 | 2024-06-15 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-05-07 | 2024-06-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-05-07 | 2024-06-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-05-07 | 2024-06-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-07 | 2024-06-15 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-05-07 | 2024-06-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-07 | 2024-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-07 | 2024-06-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-05-07 | 2024-06-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-07 | 2024-06-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-14 | 2023-06-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-26 | 2023-03-01 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-10 | 2022-12-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-10 | 2022-09-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-10 | 2022-09-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-08-10 | 2022-09-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-10 | 2022-09-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-08-10 | 2022-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-10 | 2022-09-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-10 | 2022-09-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-08-10 | 2022-09-23 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2022-08-10 | 2022-09-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-10 | 2022-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-10 | 2022-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-10 | 2022-09-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-10 | 2022-08-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-10 | 2022-08-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-05 | 2019-12-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-05 | 2019-12-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-05 | 2019-12-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-05 | 2019-12-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-05 | 2019-12-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-05 | 2019-12-17 | N |
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