Jackson Creek Senior Living

A licensure complaint, prompted by #CO41490, was completed on 2/17/26. Deficiencies were cited. Based on records review and interviews, the residence failed to implement a policy and procedure for an effective information management system that includes a method of integration of paper-based and electronic health records (EHR) that allowed effective continuity of care, including effective management for capturing, reporting, processing, storing, and retrieving care/service data and information, affecting 100 current residents.Findings Include:The residence' s "Record Keeping" policy and procedure dated 7/2025 read in part: "This community will maintain a record of all assisted living services established for each of its residents. The community must maintain and preserve all resident records in original, microfilm, electronic, or other similar form, for a period of at least five years from date of resident' s discharge. ... All records must be available for examination by responsible party of the state licensing agency."An interview on 2/17/26 with Staff #2 at 8:35 a.m. revealed that the new corporate owner of the r.. Based on records review and interviews, the residence failed to maintain complete former resident records for at least three years following the termination of the resident' s stay for Former Resident #9 (FR#9), affecting 100 current residents.Findings Include:The residence' s "Record Keeping" policy and procedure dated 7/2025 read in part: "This community will maintain a record of all assisted living services established for each of its residents. The community must maintain and preserve all resident records in original, microfilm, electronic, or other similar form, for a period of at least five years from date of resident' s discharge. ... All records must be available for examination by responsile party of the state licensing agency."In an interview with the administrator at 9:35 a.m., she explained that nearly all files dated before 1/26/26 were not retained by the new corporate owner as agreed upon, adding, "I tried to save some stuff".The health information record (HIR) for FR#9 was requested from the administrator on 2/17/26 at a.. Based on records review and interviews, the residence failed to retain for three years following an employee' s separation from employment, including the reasons for the separation, for Former Staff #4 (FS#4), affecting 100 current residents.Findings Include:In an interview with the administrator at 9:35 a.m., she explained that nearly all files dated before 1/26/26 were not retained by the new corporate owner as agreed upon, adding, "I tried to save some stuff".On 2/17/26 at approximately 2:00 p.m., the personnel file for FS#4 was requested from the administrator and not received.On 2/17/26 at approximately 2:00 p.m., the administrator confirmed that FS#4 was employed with the residence a year ago. She stated that her personnel file was lost when the residence was purchased by the new corporate owner on 1/26/26.

A licensure complaint, prompted by #CO35683, #CO35684, #CO36563 and #CO38759 was completed on 12/23/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed for each resident, affecting two of six sample residents (#11 and #12).Findings include:1. Residence PolicyThe residence' s Medication Administration policy, dated 8/10/23, read in part: "The administration of medication shall be documented at the time of administration."2. Record ReviewResident #12 was admitted to the residence on 12/17/19.A written practitioner' s order, dated 10/23/24, directed the residence to administer Cymbalta 30 mg daily. However, the November 2024 medication administration record (MAR) contained a blank space on 11/2/24.Additional deficient pra.. Based on observation, record review, and interview, the residence failed to ensure the administrator complied with all applicable state regulations to help prevent the possible development and transmission of Norovirus/Gastroenteritis and Coronavirus (COVID-19). Additionally, the residence failed to follow recommended contingency staffing protocols for their local health department (LHD), affecting 108 current residents. (Cross-reference S1130)Specifically, the residence failed to follow the LHD guidelines for reporting norovirus/gastroenteritis and collect specimens from different ill individuals. Specifically, the residence did not implement its communicable disease and infection prevention policy. The residence organized a line list of 21 residents and 13 staff members who experienced sympto.. Based on record review, and interview, the residence failed to determine appropriate routine staffing levels, and thus failed to meet requirements outlined in the resident care plan, affecting three of 108 current residents (#6, #9, #14).Findings include:1. Resident #14 was admitted to the residence on 1/14/24 with a diagnosis of dementia. A level of care evaluation, dated 1/14/24 read in part that Resident #14 did not resist care and that staff would provide maximum assistance daily with dressing, grooming, and toileting. 2. InterviewsOn 12/20/24 at approximately 5:00 p.m. Confidential Staff #9 stated that due to not having appropriate staffing levels, there were frequent times during the night and morning shifts when care needs would be missed or put off until late morning. She stated that several t.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.5 The assisted living residence shall have a policy and procedure regarding when a practitioner' s assessment of a resident is appropriate. At a minimum, the assisted living residence shall contact the resident' s primary practitioner when any of the following circumstances occur and follow the practitioner' s recommendation regarding further action.(D) The resident has known exposure to a communicable disease.

A revisit survey was completed on 3/26/24 for all previous deficiencies cited on 1/4/24. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey with complaint #CO28264, #CO28805, #CO30927, #CO32211, #CO34376 was completed on 1/4/24. Deficiencies were cited. Based on interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one of 15 sample residents (#6).Findings include:1. Residence policyThe residence' s Medication Management policy, dated 8/10/23, read in part, the residence would administer medications as ordered by a practitioner.2. Resident #6 was admitted on 3/12/22 with diagnoses including overactive bladder, actinic keratosis, spinal stenosis, complete traumatic amputation at knee level, arthritis, and malignant neoplasm of the prostate. A written practitioner' s order.. Based on observation, interview and record review, the residence failed to ensure a qualified medication administration person(QMAP) applied nationally recognized protocols for basic infection control when preparing and administering medications, affecting five of fifteen sample residents (#4, #5, #12, #13, #15 ).Findings Include:1. Reference and Residence Policya. According to the Centers for Disease Control and Prevention, Introduction to Hand Hygiene (2021), health care providers should wash their hands before touching a patient, after touching a patient or the patient' s immediate environment, and immediately after glove removal. Centers for Disease Control and Preventi.. Based on observation, record review, and interview, the residence failed to ensure the medication administration record (MAR) documented accurate information, including the date and time of administration, refusals, and resident responses to medications; all prescribed "as needed" (PRN) medications; the resident' s room location; the date the order was received, affecting five of fifteen sample residents (#1, #6, #11, #12, #14). Findings include:1. Residence PolicyThe residence ' s Medication Management policy, dated 8/10/23, read in part, Procedure: Audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and .. Based on record review and interview the residence failed to ensure personnel file included written documentation of orientation and training for three of three sample staff (#1-#3), affecting 95 current residents.Findings include:On 1/4/23 at 9:30 a.m., the personnel files for Staff #1, Staff #2, and Staff #3 were requested from the administrator. Review of the personnel files for Staff #1-#3 revealed no written documentation of completion of orientation and training.On 1/4/23 at 3:08 p.m., the regional nurse stated she was aware of the requirement to have documentation of completion of orientation and training for personnel in their personnel files. She mentioned this had been an ongoi.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.27 No stock medications shall be stored or administered by qualified medication administration persons. (A) All over-the-counter medication prescribed for administration shall be labeled or marked with the individual resident' s full name.