Jackson Manor

In the surveyor’s words

From the most serious findings on record at Jackson Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Jul 11, 2024

  Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice affected one resident (Resident #35) out of 17 sampled residents, one resident (Resident #48) outside the sample, and had the potential to affect all residents in the facility. The facility's census was 68. The facility did not provide a policy regarding the environment. 1. Observation on 07/08/24 at 2:35 P.M. of room [ROOM NUMBER] showed: - Four dime-sized brown stains and a long brown stain approximately four inches long on the divider curtain; - Scrapes and scratches on the bathroom door and trim; - Veneer missing from the sink vanity; - Scrapes on the drawers of the sink vanity; - Veneer missing on the closet door; - Scrapes on… […]

• No harm, potential for more than minimal, isolatedF628Aug 22, 2025

  Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the bed hold rate and reason for transfer for four residents (Residents #14, #16, #53, and #85) out of six sampled residents. The facility's census was 66.Review of the facility's policy titled, Discharge/Transfer – Involuntary, dated 10/07/21, showed: - The facility must provide a written notice to the resident, and if known, a family member or legal representative of the resident prior to the resident being transferred or discharged ; - The written discharge notice must contain the reason for transfer or discharge, the date of transfer, and the location to which the resident is transferred or discharged . […]

• No harm, potential for more than minimal, isolatedF658Aug 22, 2025

  Based on observation, interview, and record review, the facility failed to obtain and follow physician's orders for four residents (Residents #1, #5, #49, and #56) out of 17 sampled residents. The facility census was 66.Review of the facility policy titled, Physician Orders, last reviewed 09/28/22, showed: - Physician orders shall be provided by Licensed Practitioners (Physicians, Nurse Practitioners and Physician's Assistants) authorized to prescribe orders; - Orders must be recorded in the medical record by the Licensed Nurse authorized to transcribe such orders; - Physician orders must be documented clearly in the Medical Record. […]

• No harm, potential for more than minimal, isolatedF677Aug 22, 2025

  Based on observation, interview and record review the facility failed to provide necessary services to maintain grooming, and personal hygiene for two residents (Residents #53 and #85) out of eight sampled residents. The facility census was 66.Review of the facility's policy titled, Activities of Daily Living (ADL) Care Bathing, dated 07/21/22, showed:- Nursing staff will assist in bathing residents to promote cleanliness and dignity;- The policy did not address how often showers will be given. Review of Resident Shower Schedule, undated, showed:- Resident #53 scheduled for showers two times weekly on Tuesday and Friday;- Resident #85 scheduled for showers two times weekly on Wednesday and Saturday. 1. […]

• No harm, potential for more than minimal, isolatedF695Aug 22, 2025

  Based on observation, interview, and record review, the facility failed to change and date the oxygen tubing (a flexible tube that connects to the oxygen concentrator and delivers supplemental oxygen through the nostrils) and the humidifier bottle per physician orders. This practice affected one resident (Resident #14) out of two sampled residents. The facility census was 66.Facility did not provide a policy regarding oxygen tubing and humidification. 1. Review of Resident #14's medical record showed: - admission date of 04/16/24; - Diagnoses of chronic respiratory failure with hypoxia, dependence on supplemental oxygen; - An order to change oxygen tubing and storage bag weekly one time a day every Sunday, dated 11/24/24; - An order for oxygen at three liters continuous via nasal cannula,… […]