Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to and the facility must promote and facilitate resident
self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to promote and
facilitate self-determination when the facility failed to honor resident’s room and
roommate preferences for two residents (Resident #21 and #74); when staff failed to allow
one resident (Resident #63) to eat meals at the location of his/her choice; and when staff
took independent smoking privileges from two residents (Resident#24 and #72) who had been
assessed safe to smoke. A sample of 20 residents as selected in a facility with a census
of 84.
1. Record review of the facility’s undated policy titled, Room Changes, showed the
following:
-If room or roommate changes are indicated, inform the resident and/or family members
immediately;
-Investigate any concern for the room or roommate change;
-The resident who has concerns or needs is generally the first to be considered for a room
or roommate change;
-Assess or monitor for potential signs of any decline in physical, mental or psychosocial
well-being in the parties affected by the change.
2. Record review of Resident #74’s face sheet (a document that gives a resident’s
information at a quick glance) showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].), diabetes, and major [MEDICAL CONDITION] (mental health disorder
characterized by persistently depressed mood or loss of interest in activities, causing
significant impairment in daily life).
Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/2/19, showed the following:
-Cognitively intact;
-Limited staff assistance required for transfers;
-Extensive staff assistance required for toileting;
-Use of a wheelchair for mobility.
Record review of the resident’s progress note dated 1/4/19, at 7:37 A.M., showed Social
Worker (SW) T documented the resident has no mood or behavior issues.
Record review of the resident’s progress note dated 2/11/19, at 3:58 P.M., showed SW U
documented the resident agreed to move to a different room on 2/8/19. The resident was
notified he/she would have to ensure his/her items fit on his/her side of the room. The
resident was visibly upset due to not being able to keep some of his/her furniture.
Record review of the resident’s psychology progress note dated 2/13/19, at 5:00 P.M.,
showed the psychologist documented the resident’s affect (describes the experience of
feeling or emotion) was anxious. The resident is very dissatisfied with the move to a new
room and a new roommate. The resident would like his/her old roommate back. The resident
is willing to try a little longer to accept his/her new roommate.
Record review of the resident’s psychology progress note dated 2/20/19, at 4:20 P.M.,
showed the psychologist documented the residents affect was sad and anxious. The resident
reports difficulty resolving issues with his/her roommate. The resident wants more respect
and better communication.
Record review of the resident’s psychology progress note dated 2/27/19, no time noted,
showed the psychologist documented the resident’s affect was distressed. The resident
continues to be stressed about his/her roommate and wanted to move back in with his/her

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
previous roommate. The resident indicated he/she was at the breaking point and would
resort to hurting his/her self through nervous picking at his/her skin. The resident was
jiggling his/her legs to indicate how nervous he/she had become. He/She recommended the
resident move back in with his/her previous roommate if there is no known reason why
he/she could not. Meeting the resident’s requests will reduce anxiety and conflict with
roommate.
Record review of the resident’s progress note dated 2/28/19, at 12:53 P.M., showed SW U
documented the resident had stated concerns regarding his/her roommate. The roommate is
making him/her anxious by watching television during late hours at night and making phone
calls late at night. He/She educated both residents regarding compromising. The
psychologist contacted the SSD that the resident said that he/she would resort to nervous
picking at his/her skin if his/her desires were not met.
Record review of the resident’s psychology progress note dated 3/29/19, at 5:20 P.M.,
showed the psychologist documented the resident’s affect was distressed. The resident is
not happy and continues to have conflict with roommate.
Record review of the resident’s progress note dated 4/2/19, at 12:15 P.M., showed SW U
documented the resident has struggled to integrate with his/her roommate. He/She has been
looking into transferring to an assisted living community.
Record review of the resident’s psychology progress note dated 4/3/19, at 3:00 P.M.,
showed the psychologist documented the resident continued to be discontented with the
facility and his/her roommate. The resident feels that moving would help him/her.
During an interview on 4/17/19, at 2:41 P.M., the resident said the following:
-He/She has asked many times to have a different roommate or room due to being unhappy
with the current situation;
-He/She feels degraded by his/her roommate (Resident #21);
-Resident #21 tells the resident he/she smells and blocks him/her from coming into the
room with his/her bedside table on purpose;
-Resident #21’s television is on all the time;
-Resident #21 does not respect or communicate with him/her and yells at him/her for taking
up too much space;
-There are empty rooms, but the facility won’t let him/her move into it because the
facility gets more money if a resident needing therapy moves into the room.
3. Record review of Resident #21’s face sheet showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-No behaviors exhibited;
-Extensive staff assistance required for transfers;
-Use of a wheelchair.
Record review of the resident’s progress note dated 2/11/19, at 12:05 P.M., showed SW U
documented the resident moved to room a new room.
Record review of the resident’s progress notes, dated 2/25/19, showed SW U documented the
following:
-At 9:39 A.M., the resident was dissatisfied with his/her roommate/room;
-At 4:41 P.M., he/she spoke with the resident and the resident’s significant other about
roommate issues. The resident agreed to work on a compromise with the roommate.
Record review of the resident’s progress note dated 2/28/19, at 1:00 P.M., showed SW U
documented the resident had concerns regarding his/her roommate. The resident was given
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
education on coping skills and compromising.
Record review of the resident’s psychology progress note dated 3/6/19, at 4:20 P.M.,
showed the psychologist documented the resident’s affect was distressed. The resident is
upset because his/her roommate has been talking about him/her and wants to move out of the
room. The resident tends to blame his/her roommate for all the problems.
Record review of the resident’s progress note dated 3/12/19, at 4:45 P.M., showed SW U
documented the resident’s significant other expressed concerns regarding the resident’s
roommate encroaching on visits with Resident #21.
Record review of the resident’s psychology progress note dated 3/14/19, at 6:40 P.M.,
showed the psychologist documented the resident’s affect was distressed. The resident
reported there had been no progress with his/her roommate, they still don’t get along. The
resident feels targeted. The resident seems reluctant to accept his/her part of the
conflict.
Record review of the resident’s psychology progress note dated 3/29/19, at 5:20 P.M.,
showed the psychologist documented the resident’s affect was distressed. The resident was
unhappy and continued to complain about his/her roommate. The resident was paranoid and
said people are talking about him/her.
Record review of the resident’s psychology progress note dated 4/3/19, at 4:00 P.M.,
showed the psychologist documented the resident’s affect was sad and distressed. The
resident was unable to resolve conflict with his/her roommate and continued to be
paranoid.
During an interview on 4/17/19, at 3:13 P.M., the resident said the following:
-He/She wants a new roommate;
-He/She shares a room with Resident #74;
-Resident #74 has an odor and takes up more space in the room because he/she uses
bariatric equipment;
-He/She has talked to SW U about being unhappy with his/her roommate and wanting to change
rooms;
-He/She does not get along with Resident #74.
During an interview on 4/18/19, at 12:17 P.M., Certified Medication Technician (CMT) G
said the following:
-Resident #21 stated Resident #74 was bossy and would try to control the volume level on
the television;
-Resident #74 came to the nurse’s desk a few weeks ago crying because Resident #21 was
giving him/her the silent treatment and he/she felt upset and anxious;
-Resident #74 stated Resident #21 was a bully;
-He/She reported to the charge nurse and social services;
-The conflict between the two residents has been going on a few months since they moved in
together.
During an interview on 4/18/19, at 12:32 P.M., Licensed Practical Nurse (LPN) D said
Resident #74 complained Resident # 21 would not move his/her bedside table to let him/her
in the room.
During an interview on 4/18/19, at 2:30 P.M., SW U said the following:
-He/She tries to resolve disputes before room changes occur;
-He/she tried to resolve conflicts with Resident #74 and #21 by shutting off the
television by 10:00 P.M., and giving Resident #74 ear plugs;
-He/She was aware of the psychology notes indicating Resident #74 was unhappy with current
living situation and the resident possibly harming him/her self;
-He/She was not aware Resident #21 said anything mean to Resident #74;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-Resident #74 said he/she was uncomfortable in the room with his/her roommate and had been
spending most of his/her time out of the room;
-Both of the residents have been on the list to change rooms for a while;
-Due to Resident #74’s increased anxiety, verbalization of self-harm and psychologist
recommendations, the resident should have been moved; however, there was an issue with
availability of another room on the long-term hall;
-He/she as not sure if he/she could have been moved to a different hall.
During an interview on 4/19/19, at 10:53 A.M., SW T said the following:
-The facility is transitioning all of the long-term residents to the B hall;
-The social services department tried to work on compromising with Resident #21 and #74;
-He/She thought Resident #74 should have been moved to a different room;
-The residents should feel safe and comfortable in their room;
-He/She is not allowed to put a long-term resident on the skilled hall;
-He/She brings up room change requests in the morning meeting and a decision is made as a
group.
During an interview on 4/22/19, at 3:22 P.M., the Administrator said the following:
-The facility staff try to help resident’s compromise when they do not get along to see if
there is a solution;
-The facility involves the Ombudsman and psychologist if appropriate;
-Resident #74 and #21 asked to move in together, but then it was not working out;
-Resident #74 complained the television was too loud;
-He/She was not aware of the psychologist recommendations for Resident #74 to move back in
with his/her prior roommate or the resident talking about harming him/her self due to
anxiety;
-He/She would have moved Resident #74 if he/she had known;
-Psychology notes are usually reviewed by the Director of Nursing.
4. Record review of Resident #63’s face sheet (basic information sheet) showed the
following information:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s admission nutrition review dated 3/27/19, at 8:26 A.M.,
showed the dietary manager documented the location of most of the resident’s meals was the
resident’s room. The dietary manager documented the resident as independent in his/her
ability to eat and drink.
Record review of the resident’s baseline care plan, dated 3/28/19, showed the following
information:
-Alert/cognitively intact;
-Communicated verbally;
-Encourage self-care/participation;
-Monitor resident routines and preferences to anticipate needs;
-Encourage resident to make needs known;
-Required set up for eating;
-Staff did not document the resident’s preference to eat meals in the dining room or the
resident room;
-Monitor for safety and assist with eating/drinking as needed
Record review of the resident’s progress note dated 3/29/19, at 12:20 P.M., showed
Registered Nurse (RN) V documented the resident in his/her room and eating a meal. The
resident required assistance for set up the meals.
Record review of the resident’s admission Minimum Data Set (MDS), a federally mandated
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
assessment instrument completed by facility staff, dated 4/2/19, showed the following
information:
-Resident able to make self understood and able to understand others without difficulty;
-Resident required oversight for meals;
-Staff did not document any signs and symptoms of possible swallowing disorder.
Record review of the resident’s care plan, last revised 4/8/19, showed the following
information;
-At risk for inadequate nutrition related to poor intake, and disease process;
-Communicate with family regarding any food and weight issues;
-Create a pleasant and relaxing atmosphere while eating to increase intake;
-Discuss likes and dislikes of food;
-The care plan did not address the resident’s preference for location of meals.
Observation on 04/16/19, at 12:31 P.M., showed the resident ate the meal with his/her
right hand unassisted in the dining room. Staff were not in the dining room as the
resident ate his/her meal.
During an interview on 4/17/19, at 11:22 A.M., the resident’s family member said the
resident can mostly eat by him/her self. The resident had an observation with swallowing
study at the hospital. He/she said the new rule is the resident has to be in the dining
room for meals to be monitored while eating. The hospital said the resident was cleared
for any food he/she wanted. Resident cannot cut up food with one hand. This past weekend
was the first time someone cut up his/her food. This week was the first time, the resident
was required to go to the dining room. The resident’s family member brought pizza for the
resident and he/she was told he/she could no longer do that. The resident had to be in the
dining room.
Observation on 4/17/19, showed the following:
-At 6:21 P.M., RN V entered the resident’s room. The resident said he/she did not get a
supper tray. CNA S said the resident is not allowed to eat alone in the room. RN V and CNA
S prepared to transfer the resident to the wheelchair and take him/her into the dining
room. RN V explained to the resident why he/she cannot eat in the room alone. CNA S
explained they needed two staff to get the resident up. RN V washed his/her hands and left
the room. The resident said he/she never had a problem with swallowing before;
-At 6:40 P.M., CNA S said the resident would not get up for dinner earlier. The aides said
staff requested the resident to get up for supper at about 23 minutes to 5 P.M., but
he/she wanted to eat in his/her room and did not want to get up to the wheelchair. The
aide said he/she told the LPN at that time. The nurse talked to the resident’s family
member on the phone, explaining the resident was never supposed to eat in his/her room
alone. The resident can not eat in the room by him/her self if the resident needs
assistance or supervision. Staff cannot assist one resident in their room to eat. They
don’t have the staff for that. RN V explained to the resident, you aren’t the only one who
needs watched. CNA R said staff would bring a tray into the room when the resident’s
family member arrived. The resident will eat in his/her room when the family member
arrives to the facility;
-At 7:43 P.M., the resident sat in the wheelchair in his/her room, eating supper. The
resident’s family member stayed in the room with the resident.
During an interview on 04/22/19, at 7:40 A.M., CNA N said the resident needs his/her meals
set up, but is able to eat by self with the right hand, but should have somebody sitting
at the table while eating. Staff prefers the resident to eat in the dining room. Therapy
prefers the resident to eat in the dining room so they can watch him/her. If the resident
wanted to eat in his/her room, he/she could. Staff just have to watch and check on
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
him/her.
During an interview on 4/22/19, at 8:36 A.M., CNA A said the resident is able to eat by
self and used his/her one good arm to cut up food, unless it is really hard, then staff
will cut it up for the resident. Staff make sure the resident is in the dining room to
monitor for choking.
During an interview on 04/22/19, at 9:24 A.M., LPN O said the resident eats in the dining
room when I am working. When the resident first admitted to the facility, speech therapy
evaluated him/her and said he/she was a choke hazard so they wanted the resident to eat
with supervision. If residents need to eat in their room, they have to wait until all hall
trays are passed and then staff could assist in resident rooms if needed. The resident did
need help to cut meat due to the left side weakness, but once food is cut up he/she can
eat on own.
During an interview on 04/23/19, at 10:02 A.M., the dietary manager said the resident eats
in his/her room most of the time, with a daily intake of meals at 25 – 50%. The resident
receives Ensure twice per day, at breakfast and dinner. The resident said he/she likes
them.
During an interview on 04/23/19, at 1:53 P.M., the DON said from what she understood, it
is the resident’s preference where they want to eat. Staff will encourage a resident to
get up, but it is a resident’s choice.
During an interview on 4/23/19, at 3:37 P.M., the administrator said they encourage
residents to come out of their rooms for socialization and to decrease depression, and the
best time to encourage this is at meals. Overall, it is the resident’s choice where to
eat. When a resident is a new admission, they try to highly encourage residents in coming
out of their rooms for meals.
5. Record review of the facility’s policy title Smoking- Resident, dated 12/2016, showed
the following:
-The facility shall establish and maintain safe resident smoking practices. The procedure
will cover all types of smoking devices;
-Residents have the potential for obtaining independent smoking privileges;
-The resident’s personalized care plan will address if the resident is an independent
smoker or other requirements for smoking.
Record review of the facility’s current Smoking policy, undated, included the following
information:
-Smoking restrictions are strictly enforced in all non-smoking areas;
-Residents may not keep any smoking articles in their possession. Residents are
responsible for all cigarettes and the facility is not liable for any reported lost or
stolen;
-Residents may not have nor keep any types of lighters, lighter fluids, including butane
gas or any other forms of gas or fluids at any time;
-Residents are requested to not give smoking articles to other residents;
-Smoking is not permitted in any area other than the designated smoking areas;
-Smoking is permitted under direct staff supervision during designated smoking times;
-Staff members and volunteer workers shall not purchase and/or provide any smoking
articles for residents unless approved by the charge nurse;
-This facility may check periodically to determine if residents have any smoking articles
in violation of our smoking policies. Staff shall confiscate any such articles and shall
notify the charge nurse;
-Designated smoking area is under the pavilion in the courtyard. Only during inclement
weather, residents may smoke under the awning by A-wing.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
Record review of a memorandum located in the B-wing in-services book at the B-wing nurses’
station, showed the following information:
-As of 4/12/19, evening shift, the facility will become a supervised smoking facility. No
resident is to smoke unsupervised. Smoking times have been provided to each resident.
Residents are not to keep any smoking materials on their person or in their rooms. All
cigarettes, pipes, cigars, lighters et cetera are kept at the nurses’ desk.
-The designated smoking area is under the pavilion in the center of the courtyard unless
it is raining or below 32 degrees (Fahrenheit).
Record review of the smoking times and responsible staff, posted at the B-wing nurses’
station, showed the following information:
-From 6:30 A.M. to 6:45 A.M., nursing staff supervises residents smoking Sunday through
Saturday;
-From 9:00 A.M. to 9:15 A.M., laundry staff supervises residents smoking Saturday, Sunday
and Monday;
-From 9:00 A.M. to 9:15 A.M., nursing staff supervises residents smoking Tuesday through
Friday;
-From 11:00 A.M. to 11:15 A.M., Business Office Manager (BOM) supervises residents smoking
Monday through Friday;
-From 11:00 A.M. to 11:15 A.M., nursing staff supervises residents smoking Friday and
Saturday;
-From 1:30 P.M. to 1:45 P.M., housekeeping staff supervises residents smoking Sunday
through Thursday;
-From 1:30 P.M. to 1:45 P.M., nursing staff supervises residents smoking Friday and
Saturday;
-From 3:30 P.M. to 3:45 P.M., BOM staff supervises residents smoking Monday through
Friday;
-From 3:30 P.M. to 3:45 P.M., nursing staff supervises residents smoking Friday and
Saturday;
-From 7:00 P.M. to 7:15 P.M., nursing staff supervises residents smoking Sunday through
Saturday;
-From 9:00 P.M. to 9:15 P.M., nursing staff supervises residents smoking Sunday through
Saturday;
-From 11:00 P.M. to 11:15 P.M., nursing staff supervises residents smoking Sunday through
Saturday.
6. Record review of Resident #24’s face sheet showed staff admitted the resident to the
facility on [DATE].
Record review of the resident’s smoking risk assessment, dated 11/1/18, showed the
following information:
-The resident smoked cigarettes more than once per hour;
-The resident did not smoke in unauthorized areas; was not careless with smoking
materials; did not smoke cigarettes from ash trays; did not inappropriately provide
smoking materials to others; did not beg or steal smoking materials from others; had
general awareness and orientation; and no problems with general behavior and interpersonal
interaction;
-Moderate problem with mobility;
-Capable to follow facility safe smoking guidelines;
-Calculated smoking risk: 2 (0-9 safe smoker).
Record review of the resident’s admission MDS, dated [DATE], showed the following
information:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
-Cognitively intact;
-Required supervision for bed mobility, transfers, locomotion, dressing, eating,
toileting, and personal hygiene;
-Used a wheelchair for mobility.
Record review of the resident’s care plan, last reviewed 11/21/18, showed the following
information:
-Category: Behavioral symptoms;
-Problem: Although the resident was not allowed to smoke in his/her room, he/she could
smoke without staff supervision, in the designated smoking area, and may take smoking
materials with him/her on leave of absences (LOA);
-Goal: The resident will smoke safely without staff supervision in designated area;
-Approach: Complete a smoking safety assessment within 14 days of admission and quarterly;
observe routinely to ensure the resident is safe while smoking. Smoking is allowed during
designated times or individual preference. Smoking materials are monitored and stored by
nursing staff and are inaccessible to any resident. Lighters and other materials should be
surrendered to nursing staff upon returning from LOA. The resident is able to keep
cigarettes in his/her room; smoking with or without staff supervision is allowed in
designated area only (central courtyard).
Record review of the resident’s progress notes showed the following information:
-On 2/13/19, at 10:42 A.M., a social services designee (SSD) documented the facility held
a care plan meeting for the resident. The resident and his/her family, including his/her
spouse, attended the meeting. Staff reviewed the resident’s medical record, care plan,
face sheet, and contacts with the resident and family and made no changes. The resident
was alert and oriented, used a wheelchair for long distances and was up in his/her room as
he/she wished. The resident was independent with his/her activities of daily living.
His/her activity level remained the same; he/she enjoyed going outside to smoke.
-On 4/12/19, at 5:08 P.M., a SSD documented the resident attended a smokers meeting
regarding the new supervised smoking policy. The resident was educated verbally and in
writing regarding smoking policy. The resident placed his/her cigarettes and lighter in
the smoking box located at the A-wing nurses’ desk. Staff labeled the resident’s cigarette
packs and lighters with his/her name. Staff gave the resident a copy of the new policy and
smoking times.
Record review of the resident’s current medical record showed no indication the resident
violated any of the facility’s unsupervised smoking policy.
During an interview conducted on 4/18/19, at 1:06 P.M., the resident said he/she did not
like the new smoking policy. He/she did not like the scheduled smoking times because
he/she like to smoke when his/her spouse was resting and did not need him/her. Now, the
resident had to stop what he/she was doing to smoke or he/she had to wait until the next
scheduled smoking time.
During an interview conducted on 4/18/19, at 4:15 P.M., Registered Nurse (RN) J said the
resident did not require staff supervision when smoking because the resident no longer
smoked.
During an interview conducted on 4/22/19, at 9:58 A.M., Certified Nurse Aide (CNA) Y said
he/she knew of only one resident (Resident #24) who was upset with the new smoking policy.
The resident said when staff supervised his/her smoking; it felt like they were
babysitting him/her.
7. Record review of Resident #72’s face sheet showed staff admitted the resident to the
facility on [DATE].
Record review of the resident’s progress note dated 3/25/19, at 2:01 P.M., showed an
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
activity assistant documented the resident resided at this facility in the past and was
very familiar with the activity program. The resident preferred to stay in his/her room
most of the day and would get up around noon to smoke and socialize with peers.
Record review of the resident’s admission MDS, dated [DATE], showed the following
information:
-Cognitively intact;
-Independent with bed mobility, transfers and locomotion;
Required staff supervision with eating and personal hygiene;
-Required limited assistance with dressing;
-Used a wheelchair for mobility.
Record review of the resident’s care plan, last reviewed 4/1/19, showed the following
information:
-The resident wished to maintain as much independence, autonomy, and personal preference
as possible, which influences the choices he/she made regarding his/her care;
-Staff did not identify, develop or implement interventions regarding the resident
smoking.
Record review of the resident’s smoking risk assessment dated [DATE], at 12:08 P.M.,
showed the following information:
-The resident smoked a pipe hourly and he/she carried his/her matches/lighter;
-The resident did not smoke in unauthorized areas; was not careless with smoking
materials; did not smoke cigarettes from ash trays; did not inappropriately provide
smoking materials to others; did not beg or steal smoking materials from others; had
general awareness and orientation; no problems with general behavior and interpersonal
interaction;
-No problem with mobility;
-Capable to follow facility safe smoking guidelines;
-Calculated smoking risk: 0 (0-9 safe smoker).
Record review of the resident’s progress note dated 4/12/19, at 5:08 P.M., showed a SSD
documented the resident attended a smokers meeting regarding the new supervised smoking
policy. The resident was educated verbally and in writing regarding smoking policy. The
resident placed his/her cigarettes and lighter in the smoking box located at the A-wing
nurses’ desk. Staff labeled the resident’s cigarette packs and lighters with his/her name.
Staff gave the resident a copy of the new policy and smoking times.
Record review of the resident’s current medical record showed no indication the resident
violated any of the facility’s unsupervised smoking policy.
During an interview conducted on 4/18/19, at 12:50 P.M., the resident said the facility
recently changed their smoking policy. Now residents are only allowed to smoke with staff
at designated times. Because of the new policy, staff took the resident’s expensive pipes
and they would not give them back until the resident signed a paper that stated he/she
would not use those pipes to smoke, ever. The facility should not punish the group for one
resident’s actions.
During an interview conducted on 4/18/19, at 4:15 P.M., RN J said the resident smoked
unsupervised.
8. During an interview conducted on 4/18/19, at 4:15 P.M., RN J said staff did not
supervise residents when they smoked unless the resident tried to light a cigarette in the
building, took too many cigarette breaks, staff could not find them, or the resident was
not safe. If a resident did any of the above, he/she asked the resident if he/she wanted
staff to supervise him/her or not. If a resident did not want supervised smoke breaks,
he/she told the resident he/she had to abide by the rules, and there were consequences for
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
not following the rules. The facility did have a list of residents who required staff
supervision, but at this time, no residents required staff supervision when smoking.
9. During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said staff supervised
residents when they smoked. Residents smoking times are scheduled. Before the policy
change (4/12/19), residents could smoke independently, any time they wanted. They just
could not keep their lighter in their room. Now staff supervised all residents’ smoking.
The CNA did not know exactly what happened, but staff told him/her there was a fire or an
almost a fire with oxygen.
10. During an interview conducted on 4/22/19, at 11:34 A.M., SSD U said the facility
recently changed the residents’ smoking policy due to resident non-compliance. Staff
should document in the resident chart when a resident was noncompliant with the smoking
policy. After implementing the new policy, staff went to each resident room to collect
smoking materials. Residents had lighters in rooms, which made them non-compliant with the
(old) policy. If a confused resident entered a resident’s room who had a lighter, the
confused resident could find the lighter, posing a safety risk to all residents. Prior to
change (4/12/19), three resident required staff to supervise their smoking. All residents
were supposed to keep their lighters in desk drawer at nurse’s sta (TRUNCATED)

F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure residents do not lose the ability to perform activities of daily living unless
there is a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
supervision and/or feeding assistance for four residents (Resident #22, #26, #50, and #55)
who were identified as needed assist with meals. A sample of 20 residents selected for
review in a facility with a census of 84.
Record review of the facility’s policy titled Meal Service, dated (MONTH) (YEAR), showed
the following information:
-Assist resident to a comfortable position;
-To encourage social interaction and mobility, all residents should be encouraged to eat
meals in the dining room, per facility guidelines;
-Serve tray of food to resident;
-Place all utensils and food containers within easy reach of the resident, assist as
necessary. Give as minimal assistance to resident as possible for their well-being. Teach
and encourage use of adaptive equipment as necessary;
-Allow resident to enjoy his/her meal after you are sure you have provided adequate
assistance;
-Return periodically to determine if the resident requires further assistance;
-Remove tray as appropriate area when the resident has finished eating, but do not rush
the resident;
-Take note of the percentage of food consumed.
1. Record review of Resident #55’s face sheet (a one-page summary of important information
about a resident) showed the following information:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff), dated 3/18/19, showed the following
information:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
-Required oversight with encouragement or cueing and one person assist for eating;
-Coughing or choking during meals;
-Mechanically altered diet.
Record review of the resident’s care plan, last reviewed 3/18/19, showed the following
information:
-Set up trays at meals and assist as needed.
-Encourage fluid intake;
-Allow sufficient time to eat;
-Currently on a mechanical soft diet, with honey thick liquids.
Observation on 04/17/19 showed the following:
-At 5:31 P.M., staff served the resident’s supper tray. Staff did not assist the resident
to eat.
-At 5:37 P.M., staff were not present in the dining room assisting or cueing residents to
eat;
-At 5:38 P.M., staff were not present in the dining room to monitor or assist residents.
The resident poured drinks into his/her plate and table, placed napkin into food, and
tried to eat the napkin. The resident put napkin back on table, used hands to eat food.
The resident spilled food and liquid off table and onto resident clothing. The resident
placed his/her spoon in juice, moved the napkin around table wiping table. The resident
tried to eat the napkin a second time;
-At 5:58 P.M., another resident requested that Resident #55 be helped with his/her meal.
The Licensed Practical Nurse (LPN) V directed a passing aide to help the Resident #55. CNA
N sat with the resident and began to assist the resident with bites of food.
During an interview on 04/22/19, at 7:40 A.M., CNA R said some days, the resident can get
the food to his/her mouth okay by his/her self. If staff put food in front of the resident
and leave, the resident will spill. Some days, he/she can do okay with just cueing only,
other times the resident needs staff to assist him/her with eating. The resident has to
have someone by him/her to cue and assist.
During an interview on 04/22/19, at 8:36 A.M., CNA A said the resident needed direct
assistance for meals and needed someone to sit with him/her. A family member usually came
at lunch to assist the resident. Staff usually helped the resident at breakfast and
supper. If no one helped or sat with the resident, he/she will knock the plate over and
spill drinks.
During an interview on 04/22/19, at 9:24 A.M., LPN O said the resident had days he/she
could eat on own, some days needed assistance. The resident always needed set up. One
staff should be in the dining room every meal until all residents are finished eating.
2. Record review of Resident #22’s face sheet showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/7/19 showed the following:
-Severely impaired cognition and vision;
-Extensive staff assistance of two required for transfers;
-Extensive staff assistance of one required for toileting and hygiene;
-Set up and supervision required for eating;
-The resident did not reject care.
Record review of the resident’s care plan, last reviewed 3/27/19, showed the following:
-Instructed staff to set up the resident’s tray at meals and assist as needed;
-Instructed staff to frequently check on the resident;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
-Instructed staff to encourage the resident with his/her fluid intake;
-Identified the resident was on a mechanically altered diet.
Observations on 4/15/19, at 12:46 P.M., showed the resident in the dining area across from
the nurses’ station sitting in a high-back wheelchair, facing the wall with his/her back
towards the nurse’s station. A staff member set a meal tray on the table in front of the
resident. The staff member did not inform the resident what food was served or where on
the plate each food was located. The staff left the dining area. The resident sat and did
not begin eating. There were no staff members in the dining room. The resident drank a few
sips of a shake but did not eat.
Observations on 4/16/19, at 12:26 P.M., showed an unidentified certified nurse assistant
(CNA) set a meal tray in front of the resident. The CNA told the resident what foods were
served, but did not provide guidance for the location of the foods on the plate. The
resident picked up a hot dog bun with ground meat and the meat fell on to the resident’s
lap then onto the floor. The resident ate the bun without the meat. The resident picked up
the edge of his/her clothing protector to wipe his/her mouth and the clothing protector
dropped over the food tray and covered the resident’s food. The resident took a spoon to
get a bite and the spoon lifted the clothing protector, but did not allow the resident to
get a bite of food from under the clothing protector. There were no staff members in the
dining room to assist the resident.
During an interview on 4/22/19, at 8:15 A.M., MDS Coordinator LL said the resident does
fairly well eating independently. The resident needs supervision because some days he/she
needs encouragement or assistance. Staff should tell the resident what food is served and
the location of the food on the plate.
During an interview on 4/22/19, at 11:00 A.M., CNA A said the resident is blind. He/she
said staff should explain what is on the resident’s tray and where the food is located.
He/she said a staff member should be in the dining room during the entire meal time and
staff should assist the resident if he/she is not eating or having difficulties.
During an interview on 4/22/19, at 12:42 P.M., Licensed Practical Nurse (LPN) B said the
resident is independent with eating at most times. He/she said staff should be available
in the dining room at meal times and help the resident if he/she is not eating.
3. Record review of Resident #26’s face sheet showed the following information:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s progress notes showed the following information:
-On 1/16/19, at 1:49 P.M., the Registered Dietician (RD) documented the resident ate hot
cereal and drank his/her shake at lunch, but ate little of the rest of his/her meal. The
resident received a mechanical soft diet (foods are soft, and easy to chew and swallow),
offer cereal with each meal, and house shake three times a day with meals. He/she also
received Boost VHC (a high calorie supplement) three times a day with medications. His/her
weight was the same as it was a month ago. Staff reported the resident’s intake varied,
but seemed somewhat decreased recently. Dietary to continue to provide diet with
supplementation as ordered. Staff to continue to honor food preferences and provide foods
and beverages he/she enjoyed and was most likely to accept. Staff to continue to encourage
intake and monitor weights. No new recommendations at this time;
-On 2/6/19, at 2:11 P.M., the Dietary Services Manager (DSM) documented the resident ate,
independently, a mechanical soft diet in the assisted dining room. He/she ate an average
of 25-50% of his/her meals.
Record review of the resident’s annual MDS, dated [DATE], showed the following
information:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-Severe cognitive impairment;
-There was evidence the resident had an acute (sudden onset) change in his/her mental
status from his/her baseline;
-Inattention behavior occurred and fluctuated (came and went, changed in severity);
-Disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of
ideas, or unpredictable switching from subject to subject) occurred and fluctuated;
-Required supervision with eating;
-Used a wheelchair for mobility.
Record review of the resident’s care plan, last reviewed 2/15/19, showed the following
information:
-The resident had difficulty focusing his/her attention at times related to disease
process.
-Ensure the resident received adequate nutrition and fluids;
-Use a calm and reassuring approach;
-The resident was at risk for inadequate nutrition related to poor intake, need for
mechanically altered diet and disease process;
-Create a pleasant and relaxing atmosphere while eating to increase intake;
-Discuss like and dislikes of foods with the resident;
-Resident received a mechanical soft diet;
-Nutritional supplements as appropriate;
-Encourage fluid intake;
-Snacks as appropriate;
-Set up resident’s tray at meals and assist him/her as appropriate.
Observation on 4/18/19 showed the following:
-At 12:05 P.M., several residents sat at five tables in the assisted dining room. Two
staff members sat at two of the five tables assisting residents to eat. Resident #26 sat,
in his/her wheelchair, at a dining table with two other residents. Staff served the
resident cornbread, chicken and dumplings, green beans, and mandarin oranges. The resident
ate some of his/her cornbread, unassisted;
-At 12:12 P.M., the resident wheeled himself/herself out of the dining room. Staff did not
acknowledge the resident left the dining room and did not encourage the resident to eat.
The resident ate a few bites of his/her cornbread, a few bites of his/her green beans, and
drank a small amount of water. The resident did not eat any of his/her chicken and
dumplings and did not drink any of his/her shake;
-At 12:39 P.M., a staff member wheeled the resident into the dining room and said to CNA
JJ, maybe he/she needs to eat. CNA JJ said the resident already ate.
Observation on 4/19/19, at 11:49 P.M., showed the resident sat in the assisted dining room
eating apple crisp with ice cream. Staff served the resident macaroni salad, a chopped
hamburger on a bun, a strawberry shake, water, and Kool aid. After a few minutes, the
resident placed his/her bowl of apple crisp on the table. The resident ate a few bites of
the hamburger and none of the macaroni salad. A staff member encouraged the resident to
drink his/her shake. He/she told the resident the doctor wanted him/her to drink it. The
resident drank more than half of the shake before leaving the dining room.
During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said when staff serve the
resident a meal, the resident usually knew immediately if he/she did not want the food
staff served. When this occurred, staff offered the resident something else to eat. The
resident typically ate about 50% of his/her meals. Staff tried to encourage the resident
to eat.
During an interview conducted on 4/22/19, at 1:39 P.M., LPN D said the resident ate in the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
assisted dining room. Staff set up his/her meal tray (open silverware, take off lids, cut
up food (if needed)) and with a little encouragement he/she ate pretty well. Sometimes the
resident left the dining room to go to the bathroom, he/she may get distracted before
coming back, but he/she usually came back to the dining room to finish eating.
During an interview conducted on 4/22/19, at 3:31 P.M., CNA EE said the resident ate
independently after staff set-up his/her meal tray. Sometimes staff had to encourage the
resident to eat, other times he/she just needed supervision.
During an interview conducted on 4/23/19, at 12:23 P.M., CNA K said the resident needed
staff to set-up his/her meal tray, but he/she ate without staff assistance. He/she ate
well, but was specific on what he/she wanted. The resident was not easily distracted
unless someone else distracted him/her. He/she only left the dining room table, during a
meal, to go to the bathroom. The resident usually returned to the dining room, but if
he/she did not staff would get him/her. If the resident left without eating, staff
encouraged him/her to stay, and might offer him/her other foods.
During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said she did not
know if the resident struggled with eating
4. Record review of Resident #50’s face sheet showed the following information:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s physician order [REDACTED].
-An order dated 2/28/17, for a regular diet with mechanical soft texture;
-An order dated 9/28/17, for house shakes three times a day with meals.
Record review of the resident’s annual MDS, dated [DATE], showed the following
information:
-Severe cognitive impairment;
-Required supervision with transfers, walking and eating;
-[DIAGNOSES REDACTED].
Record review of the resident’s progress note dated 3/19/19, at 11:42 P.M., showed a
Social Services Designee (SSD) documented a care plan meeting was held for the resident.
The resident ate his/her meals in the assisted dining room. His/her appetite was poor.
His/her vision was poor. He/she requires cataract removal pending guardian approval.
Record review of the resident’s physician’s orders [REDACTED].
Record review of the resident’s care plan, last reviewed 3/21/19, showed the following
information:
-The resident was at risk for inadequate nutrition related to fluctuating intake, disease
process and mechanically altered diet;
-Create a pleasant and relaxing atmosphere while eating to increase intake;
-Discuss like and dislikes of foods with the resident;
-Resident received a mechanical soft diet;
-Encourage fluid intake;
-Snacks as appropriate;
-The resident was a slow eater. Allow the resident sufficient time to feed
himself/herself;
-The resident preferred to eat his/her meals in the main dining room;
-Set up resident’s tray at meals and assist him/her as appropriate.
Observations on 4/18/19 showed the following information:
-At 12:05 P.M., the resident walked out of the assisted dining room towards his/her room.
The resident’s silverware was wrapped with a paper towel and the resident did not eat any
food or drink any fluids. Staff did not encouraged the resident to eat, offer any
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
substitutions, or encourage the resident to drink his/her shake since he/she did not eat
his/her entr?e;
-At 12:20 P.M., the resident laid in bed with his/her eyes closed.
Observations on 4/19/19, at 11:49 A.M., showed the resident sat at a dining room table in
the assisted dining room. The resident removed his/her top dentures, removed the food
debris from his/her gums, and put his/her dentures into his/her mouth. The resident drank
his/her house shake then removed his/her top dentures and placed them on his/her plate,
then placed his/her dentures into his/her mouth. The resident did this several times. The
resident took a drink of water, and said yuck. CNA KK stood next to him/her briefly then
walked away. The CNA did not encourage the resident to eat and did not say anything to the
resident about his/her dentures on his/her plate. A few minutes later, CNA KK returned to
the resident and asked if he/she lost his/her teeth. The CNA placed a chair next to the
resident and assisted him/her to eat. After assisting the resident a while, the CNA left.
CNA KK did not ask the resident if he/she was finished with his/her meal, if he/she wanted
more food, and did not offer the resident an additional shake. The resident ate as long as
staff assisted. Without staff assistance, the resident only drank fluids. The resident ate
less than 25% of his/her lunch.
During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said if staff handed the
resident what he/she needed or told the resident what food was on his/her plate the
resident would attempt to eat. If the resident did not eat, staff encouraged him/her to
eat. The resident needed staff to set-up his/her meal tray and explain what was on the
plate because the resident did not see very well. If he/she left the dining room, staff
encouraged him/her to eat. The resident often left the dining room to wheel his/her
tablemate to his/her room.
During an interview on 4/22/19, at 1:39 P.M., LPN D said the resident would not let staff
assist him/her. Staff needed to encourage the resident to eat. He/she gets up at night
hungry. He/she liked to snack and it was a challenge for staff to get him/her to eat in
the dining room. The resident required staff to set-up his/her meal tray. The physician
ordered supplements and staff offered substitutions if the resident did not like served
food.
During an interview conducted on 4/22/19, at 3:31 P.M., CNA EE said the resident required
encouragement or guidance to eat. If the resident did not eat well, staff redirects the
resident back to his/her table.
During an interview conducted on 4/23/19, at 12:23 P.M., CNA K said the resident did not
eat anything. Staff tried to give him/her bites of foods. The resident could hardly see
his/her plate. The resident will eat a few bites of food, but then would stop eating. If
the resident really liked the food, he/she would eat unassisted, but usually after a few
bites, staff either had to encourage him/her to eat or assist him/her to eat.
During an interview conducted on 4/23/19, at 12:40 P.M., CNA X said the resident could not
see very well. Staff tried to walk with him/her to and from meals and activities. Today at
breakfast, the CNA gave the resident his/her yogurt and a spoon and the resident ate all
of the yogurt, unassisted. The resident had a hard time seeing what was on his/her plate.
If there were enough staff in the dining room, CNA X sat next to the resident and assisted
him/her to eat. The resident did not eat much by himself/herself. The resident would let
the CNA assist him/her to eat, but other staff said the resident would not let them assist
him/her.
During an interview conducted on 4/23/19, at 1:54 P.M., the administrator said she did not
know if the resident struggled with eating.
5. During an interview on 4/22/19, at 1:11 P.M., the Director of Nursing (DON) said she
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
expects a staff member to be available in the dining rooms to monitor. She said she
expects staff to assist residents if not eating and having problems eating. The DON said
interventions with eating soul be addressed on the residents’ care plan.
6. During an interview conducted on 4/22/19, at 1:39 P.M., CNA JJ said there were always
at least two staff in the B-wing assisted dining room.
7. During an interview conducted on 4/22/19, at 3:31 P.M., CNA EE said two to three staff
members assisted in the B-wing assisted dining room.
8. During an interview on 04/23/19, at 10:02 A.M., the dietary manager said they document
meal intakes for all residents in the A wing assist dining room. If a resident is in that
dining room, they need supervision, cueing, or assistance for eating.
9. During an interview conducted on 4/23/19, at 12:23 P.M., CNA K said there were usually
three staff in the B-wing assisted dining room. Two staff to assist resident to eat and
one staff to chart residents’ meal intake.
10. During an interview conducted on 4/23/19, at 12:40 P.M., CNA X said two staff assist
in the B-wing assisted dining room. After the third staff member passed hall trays, he/she
also assisted in the dining room. And if a restorative nurses’ aide (RNA) was available,
he/she too assisted in the dining room.
11. During an interview on 04/23/19, at 1:53 P.M., the DON said staff should be in the A
wing and B wing dining rooms because all those residents need cueing or assisting with
eating. Staff should be supervising in the dining room as long as residents are in there
eating. If there are three restorative staff scheduled, they are supposed to spread out to
all three dining rooms and supervise. If not, the aides should be in the dining rooms
supervising.
12. During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said at
least two staff, if not more, should be assisting in the assisted dining room. If a
resident did not eat, staff should encourage the resident and offer substitutes. They
should find out why the resident did not want to eat.

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to complete
assessments of and complete treatments as ordered on wounds for two residents (Resident
#28 and #63), out of a sample of 20 residents, in a facility with a census of 84.
Record review of the facility’s wound protocol, dated (YEAR), showed the following
information:
-Reevaluate the dressing and skin integrity every shift. Reevaluate the wounds response to
the prescribed treatment on a regular basis, and when needed, make recommendations for
treatment changes and inform the physician of changes in wound status;
-Date, time, and initial all dressings at the time of application;
-Use care when removing dressings and tapes to avoid further damage to fragile skin;
-Thoroughly document all wound information, such as type, location, stage (if applicable),
length,width, depth, drainage, notation of tunneling or undermining, description of the
tissue, state of the periwound (area surrounding the wound) area, treatment of [REDACTED].
-Notify appropriate personnel of all new pressure ulcers, or if you have any questions.
1. Record review of Resident #63’s face sheet (basic information sheet) showed the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
following information:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s progress note dated 3/26/19, at 7:53 P.M., showed the
resident admitted to the facility on [DATE]. The nurse documented left sided weakness in
both upper and lower extremity. The nurse documented no skin breakdown.
Record review of the resident’s baseline care plan, dated 3/28/19, showed the following
information:
-Alert/cognitively intact;
-Required assistance of two staff for bed mobility, transfers, and toileting;
-Staff did not identify any skin concerns;
-Staff did not include any skin prevention interventions.
Record review of the resident’s skin monitoring certified nursing assistant (CNA) shower
review sheet, dated 3/29/19, the resident had a bandage over a wound that needed
replacing. The nurse documented under the intervention the resident had a 1 centimeter
(cm) skin tear on the left upper arm. New order entered for daily dressing. The charge
nurse signed and dated the sheet on 3/29/19. The Director of Nursing (DON) signed and
dated the sheet on 4/2/19.
Record review of the resident’s physician order [REDACTED].
Record review of the resident’s progress note dated 3/29/19, at 10:09 P.M., showed a 1 cm
skin tear noted to left upper arm (LUA) during bath. Staff cleansed wound and applied
triple antibiotic ointment (TAO) and [MEDICATION NAME] dressing (a non-stick dressing).
Staff entered new order for daily dressing change.
Record review of the resident’s nurses’ (MONTH) 2019 treatment administration record (TAR)
showed on 3/30/19 and 3/31/19, the nurse documented completion of a LUA TAO and bandage
dressing change daily.
Record review of the resident’s progress note dated 3/31/19, at 8:55 P.M., showed the
nurse documented dressing changed to left upper arm, healing without signs or symptoms of
infection. The nurse did not document any further assessment or measurements of the wound.

Record review of the resident’s nurses’ TAR, dated 4/1/19 to 4/22/19, showed staff did not
document changing the dressing on 4/1/19.
Record review of the resident’s admission Minimum Data Set (MDS – a federally mandated
comprehensive assessment instrument completed by the facility staff), dated 4/2/19, showed
the following information:
-admitted to the facility on [DATE];
-Required extensive physical assistance, two or more staff, when transferring from bed,
chair, wheelchair, or standing position;
-No ulcers;
-No other skin problems, such as skin tears.
Record review of resident’s nurses’ TAR, dated 4/1/19 to 4/22/19, showed staff did not
document a dressing change on 4/2/19 or 4/3/19.
Record review of the resident’s care plan, last revised 4/3/19, showed the following
information:
-Problem start date of 3/26/19 for at risk for skin breakdown related to left sided
neglect/[MEDICAL CONDITION], malnutrition, impaired mobility, incontinence, and disease
processes;
-On 4/3/19, staff added approach of report any areas of skin breakdown to the physician as
needed for appropriate treatment orders;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
-On 4/3/19, staff added approach of weekly skin assessments by licensed nurse;
-The resident’s care plan did not address any current skin wounds.
Record review of the resident’s weekly skin assessment dated [DATE], at 11:30 A.M., showed
the resident had an existing skin issue. Staff did not document a description of the
existing skin issue or measurements on the assessment.
Record review of resident’s nurses’ TAR, dated 4/1/19 – 4/22/19, showed staff did not
document changing the resident’s dressing on 4/5/19.
Record review of the resident’s weekly skin assessment dated [DATE], at 9:00 A.M., showed
the resident had an existing skin issue. The resident had an area above the left elbow
that currently had a treatment order. Staff did not include any further description or
measurements of the existing skin issue on the assessment.
During an interview on 04/16/19, at 11:26 A.M., the resident said the left upper arm
dressing had been there about a week. It was a skin tear and he/she did not know how it
happened.
Record review of resident’s nurses’ TAR, dated 4/1/19 to 4/22/19, showed staff did not
document changing the dressing on 4/17/19 or 4/20/19.
During an interview on 04/22/19, at 9:24 A.M., Licensed Practical Nurse (LPN) O said the
resident had a skin tear on the left arm that keeps coming open, it kind of heals, but
then comes back open. He/she did not know for sure when it occurred, but it had been there
for awhile. There is a treatment in place, but it might be on the evening shift. Staff
that finds an area starts order on that shift and the treatment plan only shows up on the
shift when the treatment is due. The nurse was unsure what caused the skin tear. The nurse
did not know if the resident came with the skin tear. Staff document skin assessments
under the observation tab in the computer or under clinical assessment. The weekly skin
assessment might just show existing skin issue with treatment. If there is treatment
order, it will be on the nurse TAR. If it is an actual wound, it is documented on a wound
assessment. The MDS Coordinator MM does the weekly wound assessments.
During an interview on 04/22/19, at 11:10 A.M., the MDS Coordinator MM said she did not
know anything about resident’s left upper arm wound area. But, when the resident admitted
to the facility, there were many wraps from the hospital that appeared to be preventative.
She is not doing any assessment or monitoring of the resident’s skin tears/wounds.
During an interview and observation on 04/22/19, at 1:17 P.M., the resident said he/she
did not know what happened to his/her left arm. The resident had two bandages on his/her
left arm above the elbow with drainage visible through the dressing. The bandages did not
have any dates showing when staff changed the dressing.
Observation on 04/22/19, at 1:23 P.M., showed LPN O entered the resident room, washed
hands and applied gloves. The nurse removed two bandages, showing two open areas above the
resident’s left elbow. The resident said sometimes they are sore, but do not hurt. One
superficial open area had yellow/white macerated (the softening and breaking down of skin
resulting from prolonged exposure to moisture) skin. The other had a bruised appearance.
One area had clear drainage and one area had a small amount of blood. Each area measured
less than 1 centimeter (cm) in diameter. The nurse placed wound cleanser on gauze, patted
the wounds with the gauze, and used two smaller bandages to cover the open areas. The
nurse applied triple antibiotic ointment with his/her gloved finger, and applied two
smaller adhesive [MEDICATION NAME] bandages. The nurse dated the bandage.
During an interview on 04/23/19, at 1:53 P.M., the DON said she did not know of any wounds
on the resident.
2. Record review of Resident #28’s face sheet showed the following information:
-Readmitted to the facility on [DATE];
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
-[DIAGNOSES REDACTED].
Record review of the resident’s significant change MDS, dated [DATE], showed the following
information:
-Cognitively intact;
-Required extensive assistance for bed mobility, transfers, dressing, toilet use, and
personal hygiene;
-Staff documented the resident not at risk for pressure ulcer development;
-Staff did not document the presence of any ulcers or skin concerns.
Record review of the resident’s progress note dated 3/1/19, at 9:08 P.M., showed the nurse
documented a skin tear had resolved and treatment discontinued today.
Record review of the resident’s weekly skin assessment, dated 3/7/19, showed skin intact
with no skin issues.
Record review of the resident’s physician order [REDACTED].
-On 3/12/19, the physician ordered staff to clean the lower bilateral legs with soap and
water, pat dry, apply balm wrap with kerlix (cotton gauze wrap) every day until resolved.
Record review of the resident’s weekly skin assessment showed the following information:
-On 3/15/19, new skin issue of wound to right calf. Order received to clean the wound,
apply medi honey (gel/ointment ) to the wound bed, cover with pad, and secure with gauze
wrap. Staff to change every 3 days and as needed (PRN). The nurse did not document any a
description or measurement of the wound.
Record review of the resident’s progress note dated 3/16/19, at 12:20 A.M., showed new
skin treatment order received for the wound to the right calf. The nurse did not document
any description or measurement of the wound.
Record review of the resident’s POS, dated 3/1/19 through 4/22/19, showed the following
information:
-On 3/16/19, the physician ordered to clean the wound to the right outer calf with wound
cleanser, apply [MEDICATION NAME] to the wound bed, cover with absorbant pad and secure
with gauze wrap. Staff to change every three days and PRN.
Record review of the resident’s weekly skin assessment showed the following information:
-On 3/21/19, skin assessment completed on 3/22/19. Existing skin issue of wound to the
right calf. Order for treatment continues with no new concerns from last assessment. The
nurse did not document any description of the wound or measurements of the wound.
Record review of the resident’s progress note dated 3/25/19, at 1:38 P.M., showed the
resident continued on antibiotics and received whirlpool by hospice nurse. Treatments
completed as ordered.
Record review of the resident’s POS, dated 3/1/19 through 4/22/19, showed the following
information:
-On 3/27/19, the physician discontinued the order to clean the wound to the right outer
calf with wound cleanser, apply [MEDICATION NAME] to the wound bed, and cover with
absorbant pad;
-On 3/27/19, the physician discontinued the order to clean lower bilateral legs with soap
and water, pat dry, apply balm wrap with kerlix every day until resolved;
-On 3/27/19, the physician ordered treatment to the wound to right and left outer calf of
clean with wound cleanser, apply medi-honey to wound bed; cover with absorbent pad, and
secure with gauze wrap. Staff to change every three days and PRN.
Record review of the resident’s progress note, dated 4/2/19, showed the resident’s
[MEDICAL CONDITION] was showing some clinical improvement. The nurse did not document any
further assessment of the resident’s skin on his/her legs.
Record review of the TAR, dated 4/1/19 to 4/22/19, showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
-Staff did not complete the treatment on 4/2/19, as evidenced by parentheses around the
staff initials;
-On 4/5/19, staff left the box empty, indicating treatment not completed.
Record review of the resident’s weekly skin assessment showed the following information:
-On 4/12/19 the nurse completed the skin assessment from 4/11/19. Existing skin issue,
areas on both legs, and currently receiving treatment. No reports of any other skin issues
at this time. The nurse did not document any further assessment of the wounds or
measurements of the wounds.
Observation on 04/17/19, at 2:01 P.M., showed CNA S and CNA R provided personal care for
the resident. The resident’s right lower leg had a dressing, dated 4/8/19 (nine days
prior).
Observation on 04/18/19, at 10:13 A.M., showed CNA A entered the resident’s room. The aide
checked the resident for incontinence. The resident’s left lower leg had a dressing dated
4/27/18 and a right lower leg dressing dated 4/8 (ten days prior).
Record review of the TAR, dated 4/1/19-4/22/19, showed on 4/20/19 staff left the box empty
indicating treatment not completed.
During an interview on 04/22/19, at 9:24 A.M., LPN O said the resident’s two areas were
maybe skin tears. The nurse did not know for sure. He/she said the treatment is completed
on evening shift. The nurse thought the resident maybe bumped his/her leg on the
wheelchair. The date on the dressing would be the date the dressing change was completed
by staff. Observation with LPN O showed the resident’s left leg wrapped with no date on
the dressing and the right leg dressing with the date of 4/8 (14 days prior).
During an interview on 04/22/19, at 11:10 A.M., the MDS Coordinator MM said she is
responsible for all wound assessments in the facility and monitor the wounds once per
week. She said the resident’s legs will swell and get blisters and then pop. Usually, a
wrap is done and some kind of treatment. This was not usually something staff would
document as it is on such a grand scale. She would not know what to say about them, whole
bunch of tiny ones from knee to ankle. The nurse does not do any monitoring or assessments
of the resident’s wounds.
During an interview on 04/22/19, at 2:22 P.M., LPN M said awhile back, hospice had an
order for [REDACTED]. He/she had not done a treatment since the end of March. He/she did
not know who was doing the treatment. He/she puts a smiley face on the dressing, not a
date. The nurse started working at the facility on 3/20/19.
Observation on 04/22/19, at 3:20 P.M., showed LPN M prepared wound care supplies at the
medication cart in hall and entered the resident’s room. The LPN removed a gauze bandage
with scissors from the right leg dated 4/8 with staff initials. The nurse said this was
LPN GG based on the initials. The area measured approximately 1 cm in diameter with 1 cm
line x 1/8 cm wide (like a key shape but smooth edges), area open and red, but no redness
surrounding the wound. A small about of drainage was the gauze pad removed from wound. The
nurse removed the left leg wrap that had no date or initials on gauze. The left leg wound
measured 1 cm open, red with minimal drainage on dressing, no red streaks, and not warm to
touch per the LPN.
During an interview on 04/23/19, at 1:53 P.M., the DON said she did not know about any
wounds on the resident’s legs.
3. During an interview on 04/22/19, at 11:10 A.M., MDS Coordinator MM said he/she is
responsible for wound assessments for the whole facility. She monitors everything from
skin tears, pressure ulcers, surgical wounds, and non-pressure wounds. She monitors them
once a week and documents on the computer program under the observations tab. They are
labeled initial and weekly wound documentation. She sometimes looks at referrals, if
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
someone is a new admission for any wounds. She looks to see if a resident had a wound at
the hospital prior to admission. Some wounds she catches from the clinical assessment that
nurses complete on admission. Aides complete a shower sheet with each shower or bath and
turn the sheet in at the nurses’ station. The administrator, DON, or the MDS Coordinator
MM look through the shower sheets, depending on who has time. Nurses sign off on the the
shower sheets before the end of the shift. Nurses call the physician for a treatment
order. The MDS Coordinator MM runs a facility activity report of notes, vital signs, and
observations every morning. She finds out about wounds from the documentation, or day
shift or evening shift staff come tell her. Staff will also put a note under door. The
nurses do the skin assessments on a weekly rotation. It pops up on their TAR. If a
resident has a wound, the skin assessment just tells if the resident has a wound, It does
not contain any description or measurement of the wound. That information would be
documented in a wound assessment.
4. During an interview on 04/23/19, at 1:53 P.M., the DON said in general, if skin concern
found by staff, it should be written on skin assessment sheets, DON notified, and the
physician notified there is a problem. The nurse should document in a progress note. If
there was an incident, that should be documented. When documenting the wound, it should
have the cause of the wound if known, description of the wound, and measurements. The
nurse should notify obtain treatment orders.

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, observation and interview, facility staff failed to report, assess
and document newly acquired pressure ulcers for two residents (Resident #26 and #50),
failed to develop and implement interventions for the prevention and treatment of pressure
ulcers for two residents (Resident #26 and #50), and failed to perform a pressure ulcer
treatment for one resident (Resident #50) in a selected sample of 20 residents. The
facility’s census was 84.
Review of facility’s pressure ulcer, care and prevention of policy, dated (MONTH) (YEAR),
included the following information:
-Treatment of pressure ulcers will vary depending on the orders of the attending
physician. The nurse was responsible for carrying out the treatment as ordered by the
attending physician and for implementing measure to prevent pressure ulcers.
-Equipment: skin lotion, elbow protector, heel protector, pressure reducing mattress,
pressure reducing chair pad, foot cradle, pillows;
-Observe skin. Any persistent reddened area that remains after pressure is relieved is a
high-risk area for a pressure ulcer to begin.
-Apply skin lotion gently to dry skin.
-Change bed linen promptly when wet or soiled.
-Keep sheets dry, free of wrinkles and free of debris.
-Use pressure-reducing devices to relieve pressure.
-Turn resident every two hours and position with pad or pillows to protect bony
prominences.
-Whenever possible, teach the resident to change his/her own position at regular intervals
and shift his/her weight in wheelchair.
-Use elbow and heel protectors if needed.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 21)
-Use a bed cradle (a frame used to keep the sheets and blankets from laying directly on a
person’s skin while in bed) to relieve pressure of bed clothing, if needed.
-Assist resident at mealtime to assure adequate nutrition.
-Offer fluids frequently for adequate hydration.
1. Record review of Resident #26’s face sheet (a summary of important information about a
resident) showed the following:
-Readmitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s pressure ulcer risk assessment, dated 1/23/18, showed the
staff scored the resident as an 18, which indicated the resident was at risk for pressure
ulcer development.
Record review of resident’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 2/11/19, showed the following information:
-Severe cognitive impairment;
-Required extensive assistance with bed mobility, transfers, dressing, toileting and
personal hygiene;
-Used a wheelchair for mobility;
-Always continent of bowel and bladder;
-At risk for developing pressure ulcers;
-No pressure ulcers;
Pressure-reducing device for his/her chair;
-Pressure-relieving device for his/her bed.
Record review of the resident’s care plan, last updated 2/15/19 showed the following
information:
-Urinary Incontinence: the resident was at risk for complications related to incontinence
of bowel and/or bladder;
-Give the resident good perineal care after each incontinent episode;
-Observe for redness and breakdown in the resident’s perineal area when the resident
toileted;
-Weekly skin assessment by licensed nurse.
-At risk for skin breakdown related to history of pressure ulcers, impaired mobility,
incontinence, and disease process;
-Apply moisture barrier as appropriate;
-Check the resident’s position in the wheelchair and bed regularly. Assist the resident to
make changes as needed.
-Clean and dry the resident’s skin after each incontinent episode.
-During my staff assisted shower, document and report any areas of redness or breakdown to
the charge nurse.
-Report any areas of skin breakdown to the physician as needed for appropriate treatment
orders.
-Weekly skin checks by the licensed nurse with quarterly pressure ulcer risk assessments;
-Required assistance of one staff for all of his/her activities of daily living related to
weakness, impaired mobility and disease process, including transfers and toileting;
-Up in a wheelchair daily, assist of one staff to transfer.
Record review of the resident’s (MONTH) 2019 physician’s orders [REDACTED].
Record review of resident’s progress note, dated 4/9/19, showed a social services designee
(SSD) documented the resident would discharged from Hospice services at midnight on
4/11/19 as the resident no longer met hospice criteria for services.
Record review of the resident’s weekly skin assessment, dated 4/16/19, showed a nurse
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
documented the resident’s skin was intact, no skin issues.
Observations on 4/15/19 and 4/16/19 showed the resident propelled himself/herself in a
wheelchair throughout the facility. The resident sat up in his/her wheelchair all day.
He/she did not have a pressure reducing cushion in his/her wheelchair. He/she sat on a
folded blanket.
An observation and interview on 4/17/19 on 7:39 P.M., showed Certified Nurse Aide (CNA) Q
wheeled the resident to his/her room. The resident stood up from his/her wheelchair and
showed a visible dark yellow ring of wetness in the center of the folded blanket where
he/she sat. The resident did not have a pressure relieving cushion in his/her wheelchair.
The CNA pulled down the resident’s pants and incontinent brief. The resident was
incontinent of urine, visible in his/her saturated brief. Urine leaked from the resident
brief through his/her pants onto the folded blanket in his/her wheelchair. The brief was
so full of urine, it caused his/her pants and folded blanket to be wet. The strong urine
odor from the resident brief permeated the bathroom. CNA Q took off the resident’s pants
and said they were wet and he/she retrieved a clean pair of pants from the resident’s
closet. After the resident finished, he/she stood up for the CNA to clean him/her. The
resident had three apple seed-sized raised areas on his/her left inner buttock and his/her
perineal area was reddened. The CNA said one of the raised areas was soft, one was hard
and the third looked like a bite. He/she also said the resident’s perineal area was
reddened. The CNA wiped the resident’s inner buttocks, one time, with a disposable wipe,
and dressed the resident in a new brief and pants.
Observations on 4/18/19 showed the resident sat in his/her wheelchair all day. He/she did
not have a pressure-reducing cushion and sat on a folded blanket.
An observation on 4/19/19, at 12:30 P.M., showed CNA X assisted the resident with a
shower. The CNA dried off the resident’s feet and showed a small circular scabbed area on
the fourth toe of his/her right foot. The resident stood up and showed on circular, dark
red area, a little smaller than a pencil eraser, on his/her left inner buttock. The
resident’s perineal area was reddened with peeling skin. After the CNA dressed the
resident, he/she transferred him/her to the wheelchair. The resident’s wheelchair did not
have a pressure re cushion for the resident to sit on.
Record review of Skin Monitoring: Comprehensive Certified Nurse Aide (CNA) Shower Review
sheet, dated 4/19/19, showed the following information:
-A CNA documented the resident had reddened and peeling skin on his/her buttocks.
-On 4/19/19, the charge nurse signed the sheet indicating he/she reviewed it;
-On 4/22/19, administrator signed the sheet, indicating she reviewed it;
-A staff member documented was also given to MDS coordinator (MM)/ wound nurse to assess.
(The staff member did not document the date he/she gave MDS coordinator MM the shower
sheet).
During an interview on 4/19/19, at 2:18 P.M., LPN D said the resident had a pressure
reducing cushion in his/her wheelchair. When Hospice discharged the resident, they
probably took it when they picked up their equipment. He/she should have noticed the
resident did not have a pressure reducing cushion in his/her wheelchair, before now.
An observation on 4/22/19, at approximately 9:30 A.M., showed the resident sat in his/her
wheelchair. The resident did not have a pressure reducing cushion in his/her wheelchair.
During an interview conducted on 4/22/19, at 11:18 A.M., the Rehabilitation Director said
the physician had to write an order for [REDACTED]. He randomly screened residents
throughout the week for positioning devices. If a resident had a pressure ulcer or
complained of pain in his/her buttocks, he completed a screen on that resident as well.
The rehabilitation director did not know if the resident continued to receive Hospice
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 23)
services but he thought Hospice provided the resident with a pressure-reducing cushion. He
wanted to screen the resident for the last two to three weeks but he was waiting for
resident Hospice to discharge him/her. The rehabilitation services director found out
about new wounds through daily morning meetings, as well as, during the weekly residents
at risk (RAR) meeting.
During an interview conducted on 4/22/19, at 1:39 P.M., LPN D said the resident now had a
Roho cushion. The resident received Hospice services and recently they discharged him/her
from services. Hospice staff took the resident’s cushion when he/she discharges and we did
not catch that until last Friday afternoon (4/19/19). Therapy screened residents for
positioning devices but they probably did not screen the resident because he/she received
Hospice services. The LPN had not recently observed the resident’s skin. If a CNA found a
skin concern when assisting a resident with a shower, the CNA would report the issue to
the charge nurse.
An onservation on 4/22/19, at 1:56 P.M., the resident sat, with his/her eyes closed, in
his/her wheelchair in the B-wing dining room. The resident sat on a pressure-reducing
cushion.
Record review of the resident’s Medication Administration Record [REDACTED]
-An order, dated 3/14/19, for a ROHO cushion to the resident’s wheelchair each shift;
-Day shift (6:00 A.M.-2:00 P.M.) staff documented the item was unavailable on 4/1/19
through 4/8/19, 4/10/19, 4/11/19, 4/14/19, 4/18/19, 4/19/19, and 4/22/19.
-Evening shift (2:00 P.M.-10:00 P.M.) staff documented the item was unavailable on 4/1/19
through 4/4/19, 4/6/19 through 4/8/19, 4/10/19, 4/14/19, 4/15/19, 4/16/19, 04/19/19,
04/22/19. On 4/18/19, evening shift staff documented the resident refused the item;
-Night shift staff (10:00 P.M.-6:00 A.M.) documented the item was unavailable on 4/1/19
through 4/3/19. On 4/4/19, night shift staff did not document if the resident had the
cushion or not. On 4/18/19, night shift staff documented the resident refused the item.
Review of the resident’s progress notes, 4/17/19-4/22/19 showed no documentation a nurse
assessed the reddened areas on the resident’s buttocks or the small scab on the resident
fourth toe.
Record review of the weekly skin assessment, dated 4/23/19, at 1:00 A.M., showed a nurse
documented the resident’s skin was intact.
An observation on 4/23/19, at 9:26 A.M., showed the following:
The DON and MDS coordinator MM removed the resident’s house shoes and observed his/her
feet. The resident had a small circular area on the fourth toe of his/her right foot. The
MDS Coordinator said she did not know what to call the area, maybe an abrasion or pressure
area from his/her shoes. The resident had issues with his/her feet, off and on. His/her
shoes were tight and he/she had a lot of swelling in his/her feet.
-The DON and MDS Coordinator MM assisted the resident to the bathroom. The MDS Coordinator
said the resident had a pea-sized, Stage II pressure ulcer, with flaky skin, on his/her
left buttock. The resident had a pressure ulcer in this area before and she considered
this a reopening of an old pressure area. The resident’s inner buttocks were reddened.
Record review of the resident’s weekly initial and weekly wound documentation, dated
4/23/19, at 1:00 A.M., showed a nurse documented the resident’s skin was intact.
Record review of resident’s initial and weekly wound documentation, dated 4/23/19, showed
the following information:
-Date of onset: 2/23/19, new area;
-Acquired at the facility;
-Left inner, mid buttock, pressure ulcer Stage II (a partial thickness loss of skin layers
that presents as an abrasion, blister, or shallow crater) that measured 0.5 centimeters
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 24)
(cm) X 0.3 cm X 0.1 cm.
-Granulation (pink or red tissue with a shiny, most, granular appearance) tissue present
in the wound bed
-Scant amount of bloody drainage and no foul odor.
-Surrounding tissue intact;
-Interventions: Pressure reducing device for bed, pressure ulcer care (no pressure ulcer
device for chair).
Record review of the resident’s medical record showed no documentation of the small
pressure area on the resident fourth toe, right foot.
During an interview conducted on 4/22/19, at 4:05 P.M., CNA Q said the resident’s skin was
fragile. He/she had not seen the resident’s skin since last week, but he/she remembered
the resident had three little bumps on his/her inner left buttocks that were firm but not
fluid-filled. His/her buttocks were not red at that time. The CNA knew he/she told the
charge nurse about the three small bumps but he/she did not remember whom he/she told.
During an interview conducted on 4/22/19, at 9:20 P.M., Registered Nurse (RN) J said
he/she did not know the resident had three small raised areas on his/her inner left
buttock. Social services staff asked him/her, today, to assess the resident’s buttocks.
During an interview conducted on 4/23/19, at 12:39 P.M., CNA X said the CNAs completed a
shower sheet with each resident shower. The CNAs gave the sheets to the nurse, the nurse
then reviewed it, signed it, and placed it in the medical records tray at the nurses’
station. If the CNA found something concerning, he/she would report it to the nurse.
During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said MDS
Coordinator MM told her about resident’s pressure ulcer today. The administrator reviewed
the resident’s shower sheet yesterday and she asked RN J to complete a skin assessment on
the resident.
During an interview conducted on 4/23/19, at 3:38 P.M., the DON said if an aide observed a
new skin issue, he/she should report it to the charge nurse. The nurse should assess the
area, document the assessment in the progress notes and weekly skin assessment and notify
the physician. The nurse should also report the skin issue to the DON and MDS coordinator
MM.
2. Record review of Resident #10’s face sheet showed the following:
-Readmitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of resident’s quarterly MDS, dated [DATE], showed the following information:
-No cognitive impairment;
-Independent with bed mobility, transfers, dressing, eating. Toileting and personal and
hygiene;
-Used a wheelchair for mobility;
-At risk for pressure ulcers;
-No pressure ulcers;
-Pressure-reducing device for his/her bed;
-Application of ointments/medications other than to feet.
Record review of the resident’s care plan, last reviewed 1/23/19 showed the following
information:
-The resident was risk for skin breakdown related to obesity and disease process;
-Apply moisture barrier as appropriate;
-Check the resident’s position in his/her wheelchair and bed regularly. Assist him/her to
make changes as needed.
-Clean and dry his/her skin if he/she should have an incontinent episode.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 25)
-Complete his/her Braden scale (a tool used to help determine a resident’s risk of
developing a pressure ulcer) quarterly and as needed.
-During staff assisted showers, document and report any areas of redness/breakdown to the
charge nurse.
-Report any areas of skin breakdown to the physician as needed for appropriate treatment
orders.
-Weekly skin checks by the licensed nurse with quarterly pressure ulcer risk assessments.
Record review of the resident’s progress notes, dated 4/9/19, showed a nurse documented
the resident returned from the hospital and had a Stage I pressure ulcer to his/her right
coccyx. The nurse did not document a description of the area including size and
surrounding tissue.
Record review of the resident’s physician order, dated 4/9/19, showed an order to clean
the right coccyx (tailbone) Stage I pressure ulcer with wound cleanser and apply a
[MEDICATION NAME] (an adhesive dressing) every other day and as needed.
Record review of the resident’s (MONTH) 2019 treatment administration record (TAR) showed
the following information:
-an order for [REDACTED].>-Staff documented they did not change the dressing on
4/11/19, the resident was unavailable; 4/13/19, the resident was unavailable; 4/15/19, due
to time constraints; 4/17/19, the resident was unavailable; and 4/19/19, due to time
issues.
Record review of the resident’s Skin Monitoring: Comprehensive CNA Shower Review forms
showed the following information:
-On 4/16/19, at 5:15 A.M., a CNA documented the resident received a shower. On 4/16/19, a
nurse documented no skin issues reported to this nurse. On 4/16/19, the DON signed the
form;
-On 4/16/19 a CNA (a different CNA than who documented on the above shower sheet)
documented the resident received a shower. The resident had a reddened area on his/her
buttocks. On 4/16/19 a nurse (a different nurse than who signed the above shower sheet)
documented he/she reviewed the shower sheet. On 4/17/19, the administrator signed the
form.
During an interview conducted on 4/17/19, at 2:06 P.M., the resident said he/she had a
dressing on his/her buttocks but he/she removed it yesterday (4/16/19) when he/she took a
shower. He/she removed it because he/she in case it had fecal material on it. Staff placed
the dressing on his/her buttocks the day he/she readmitted to the facility (4/9/19).
During an interview conducted on 4/18/19, at 4:20 PM RN J said the Stage I pressure ulcer
on the resident’s buttocks was healing well. He/she observed it a long time ago. The
resident said he/she did not want staff messing with it, so he/she backed off the
treatment. The resident had an air mattress but it staff took it off his/her bed because
another resident needed it more. The RN did not know why staff would document they did not
complete the treatment because the resident was unavailable. Ig the RN did not complete a
treatment, he/she would always document why he/she did not complete it on the TAR.
An interview and observation on 4/19/19, at 8:33 A.M. and 10:55 A.M., showed the following
information:
-At 8:33 A.M., a CNA walked with the resident as he/she propelled his/her wheelchair into
his/her room. The resident stood up and pulled down his/her pants and showed, on his/her
right buttock, an apple seed-sized open area with white flaky skin surrounding and partly
covering the wound bed. On his/her left buttock, the resident had a pea-sized white, flaky
scabbed area. His/her perineal area was reddened. The resident did not have a pressure
reducing cushion in his/her wheelchair. He/she sat on three folded cloth pads.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 26)
-The resident said he/she had a history of [REDACTED]. In the past, therapy staff placed a
pressure-reducing cushion in his/her wheelchair but it was too thick and his/her feet did
not reach the ground to propel his/her wheelchair. The resident got the wheelchair he/she
currently sat in seven or eight years ago. The wheelchair was broken; the seat sagged so
if he/she placed a smaller cushion in the wheelchair, it slid out the back of the chair.
-The resident said about four or five months ago, staff placed an air mattress on his/her
bed. The resident asked staff to remove it one to two weeks later due to severe back pain.
He/she thought the air mattress caused his/her back pain and a regular mattress would
help. The staff removed the air mattress but his/her back pain remained. The resident
recently found out he/she had a broken back. The resident wished he/she never asked staff
to remove the air mattress. At the beginning of (MONTH) 2019, the resident asked a nurse
if he/she could have the air mattress back. The nurse said the physician would have to
write an order for [REDACTED]. The resident did not talk to the nurse practitioner about
an air mattress because he/she it was a moot point; he/she did not have a big enough issue
to get one.
-The resident pointed to his/her bed and said he/she placed a pillow, under mattress, and
positioned several folded blankets under his/her bottom and upper legs to hopefully avoid
developing any more sores. The resident had a history of [REDACTED].
Record review of a psychiatric consult, dated 2/20/19, showed the psychologist documented
the resident reported he/she could not sleep through the night due to extreme pain. He/she
was waiting to get the (air) mattress back.
During an interview conducted on 4/19/19, at 2:18 P.M., LPN D said in the past, the
resident had an air mattress and a pressure reducing cushion in his/her wheelchair. The
LPN did not know the resident currently wanted either of those items. If a nurse could not
complete a treatment because a resident was unavailable, the nurse would report this to
the oncoming shift to complete. If staff already documented completing the treatment, but
was actually unable to complete the treatment, staff should add an addendum describing the
situation, but he/she did not know if staff knew how to do that.
During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said the resident sat on a
green folded pad instead of a wheelchair cushion because the cushion the resident tried
was too thick and the resident’s feet did not reach the floor. The CNA did not know what
resident’s skin looked like since resident took himself/herself to the bathroom. The CNA
thought the nurse checked the resident’s skin. The resident used to have an air mattress
on his/her bed, but the CNA did not know if he/she still had one. He/she thought the
resident wanted the mattress removed because it hurt his/her back.
An observation and interview conducted on 4/22/19, at approximately 10:00 A.M., showed the
resident propelling his/her wheelchair down the hall, towards the main dining room. The
resident said, in an irritated tone, he/she did not need staff (LPN D) to look at his/her
skin; it was fine.
During an interview conducted on 4/22/19, at 11:18 A.M., the Rehabilitation Director said
the resident did have a cushion but he had not looked at the resident recently because the
resident was good about talking to him when he/she needed something. The rehabilitation
director did not know the resident’s wheelchair was broken. In terms of a properly fitting
cushion, he would assess the resident’s wheelchair to ensure it was in the lowest
position.
During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said she did not
know resident had skin issues. If staff were unable to complete a physician’s orders
[REDACTED].
3. During an interview on 4/19/19, at 2:18 P.M., LPN D said the nurses completed skin
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
assessments weekly for each resident. The physician determined and ordered interventions
related to residents’ skin issues.
During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said pressure ulcer
interventions included consistently turning and repositioning residents and placing
pillows between their knees. All residents should have a cushion in their wheelchair
unless they requested not to.
During an interview conducted on 4/22/19, at 1:39 P.M., LPN D said to prevent pressure
ulcers staff reposition residents, provide skin care, and apply barrier cream, if needed.
Ideally, all residents who use a wheelchair for mobility should have a cushion.
During an interview conducted on 4/22/19, at 9:20 P.M., RN J said if he/she found or if
staff reported a new skin issue, he/she assessed the area, documented the assessment in
the nurse’s notes and notified the doctor.
During an interview conducted on 4/23/19, at 12:23 P.M., CNA K said when a CNA assisted a
resident with a shower, he/she completed a shower sheet and gave the sheet to the nurse to
review. If a CNA documented a skin issue on the shower sheet, the nurse compared the sheet
to what he/she knew about the resident, he/she signed the sheet and placed it in medical
records’ tray at the nurses’ desk. If the CNA found a new area on a resident’s skin,
he/she reported the area to the nurse. If a resident’s perineal area were reddened, he/she
would first perform perineal care on the resident; if it were still red, he/she would
report the redness to the nurse.
During an interview conducted on 4/23/19, at 12:49 P.M. and 1:43 P.M., LPN D said the
following:
-After the CNA gave the shower sheet to the nurse to review the nurse signed the sheet and
placed it in the tray at the nurses’ station for the administrator to review;
-If a resident had a new wound, he/she would notify the physician and wound nurse. If the
wound nurse was at the facility, she would assess the wound. If the wound nurse was not at
the facility, the LPN would assess the wound and document the assessment in the progress
notes.
During an interview conducted on 4/23/19, at 1:54 P.M., the administrator said
interventions for pressure ulcer prevention and treatment included turning and
repositioning, and a pressure-reducing cushion in the wheelchair. Staff should report any
new skin areas to the nurse and the nurse should assess and document the assessment in the
progress note or on a skin assessment. The nurse then should give a copy of the progress
note or skin assessment to MDS Coordinator MM, who was the wound nurse at this time. The
administrator said they did needed to do a better job following up on skin concerns.

F 0687

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate foot care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview, the facility failed to ensure proper
treatment and care to maintain good foot health for one resident (Resident #26) who was
diabetic, had untreated painful callouses on his/her foot and complained of foot pain, in
a selected sample of 20 residents. The facility’s census was 84.
1. Record review of Resident #26’s face sheet (general information) showed the following
information:
-Readmitted to the facility on [DATE];
-[DIAGNOSES REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0687

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 28)
Record review of resident’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 2/11/19 showed the following information:
-Severe cognitive impairment;
-Required supervision for locomotion throughout the facility;
-Required extensive assistance with transfers and dressing;
-Used a wheelchair for mobility.
Record review of the resident’s care plan, reviewed 2/15/19, showed the following
information:
-The resident’s nails should be cut routinely by licensed staff only;
-Observe my skin for impairment in integrity. Weekly skin assessments by licensed nurse;
-Ensure the resident wears appropriate footwear to minimize trauma to his/her feet.
Record review of the resident’s (MONTH) 2019 physician order [REDACTED].
Record review of resident’s progress note, dated 4/9/19, showed a social services designee
(SSD) documented the resident would discharged from Hospice services at midnight on
4/11/19 as the resident no longer met hospice criteria for services.
Observations on 4/17/19 showed the following information:
-At 6:38 P.M. and 7:18 P.M., the resident propelled his/her wheelchair up and down the
halls of the facility. Resident wore house shoes and nonskid socks. The resident’s house
shoes were not completely on the resident’s feet causing the resident to step on the sides
of the house shoes when he/she propelled his/her wheelchair;
-At 7:39 P.M., Certified Nurse Aide (CNA) Q assisted resident to bathroom. The resident
continued to wear nonskid socks and house shoes, stepping on the sides of the house shoe.
When the CNA removed the resident’s house shoes and socks, the resident told the CNA to be
careful; his/her feet were sore. The resident’s feet were swollen and reddish purple. The
CNA placed the resident’s feet properly into the house shoes, without the nonskid socks.
An observation on 4/19/19, at 12:30 P.M., showed CNA X assisting the resident with a
shower. The resident’s feet were swollen and bluish purple in color. The CNA lifted the
resident left foot and showed a garbanzo-sized, hard, white area, approximately two inches
below his/her great toe, and pea-sized, hard, white area approximately one inch below
his/her fourth toe. The resident said his/her foot was tender to the touch, and then
he/she said both of his/her feet were tender. The toenails on the resident’s feet were
yellowish, long and thickened.
Record review of Skin Monitoring: Comprehensive CNA Shower Review sheet, dated 4/19/19,
showed the CNA documented the resident’s feet were blue/purple. On 4/19/19, a nurse signed
the shower sheet indicating he/she reviewed it. On 4/22/19, the administrator signed on
the form.
An interview conducted on 4/22/19, at 1:39 P.M., Licensed Practical Nurse (LPN) D said the
resident complained of foot pain, in the past, but it had been awhile. Social services
staff schedule resident visits with the podiatrist. If a resident had thick nails or
complained of foot pain, he/she might see the podiatrist.
An observation on 4/22/19, at 3:51 P.M., the resident propelled his/her wheelchair up and
down the halls of the facility. Resident wore house shoes and nonskid socks. The
resident’s house shoes were not completely on the resident’s feet causing the resident to
step on the sides of the house shoes when he/she propelled his/her wheelchair.
An observation on 4/23/19, at 9:26 A.M., the Director of Nursing (DON) and MDS coordinator
MM wheeled the resident into his/her room and asked if his/her feet hurt. The resident
said no and lifted his/her feet up and down as if he/she was running, but he/she did not
touch his/her left foot to the floor. The MDS coordinator removed the resident’s house
shoes; his/her feet were swollen and reddish purple. On his/her left foot he/she had a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0687

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
garbanzo-sized, hard, white area, approximately two inches below his/her great toe, and
pea-sized, hard, white area approximately one inch below his/her fourth toe. The MDS
Coordinator said the resident had two callous’ on the bottom his/her left foot. The
resident had issues, off and on, with his/her feet. His/her feet swelled and his/her shoes
were tight. The DON said the resident’s toenails were a little thick. The MDS coordinator
found a pair of slip on shoes in the resident’s closet and brought them to him/her. The
resident said those shoes hurt his/her feet. The DON said the shoes might cut into the
sides of the resident’s foot (due to swelling). The resident said he/she tried to wear the
shoes yesterday but took them off because they hurt his/her feet. The DON and MDS
coordinator assisted the resident to the bathroom. During the transfer, the res did not
step down or put pressure on his/her toes and the ball of her right and left foot; when
he/she walked he/she walked on his/her heels. The MDS coordinator said she noticed how the
resident walked during the transfer and she figured those calluses were pretty sore. The
resident said his/her toes and feet hurt badly. He/she placed his/her left foot on his/her
right leg and rubbed it multiple times.
The DON wondered if the podiatrist had seen the resident and MDS coordinator MM said she
did not know, but she would ask SSD T if the resident was on the podiatrist’s list.
During an interview conducted on 4/23/19, at 10:45 A.M., SSD T and SSD U said a podiatrist
came to the facility every three months. The SSDs determined who saw the podiatrist and
wrote a list. They announced the upcoming podiatry visit in resident council and if any of
those residents wanted to see the podiatrist, he/she told one of the SSDs and she would
write the resident’s name on the list. The SSDs also included residents with diabetes and
those who had a specific physician’s orders [REDACTED]. If a resident did not attend
resident council meetings, did not have a specific physician’s orders [REDACTED]. The SSDs
did not know why the podiatrist had not seen the resident and they were unable to locate
podiatrist’s list at that time. One of the SSDs said the resident did not want fitted for
shoes, but it depended on the day. The SSDs did not have any documentation that showed
they offered to fit the resident for shoes. A short time later, at approximately 11:00
A.M., one of the SSDs said the podiatrist did not fit the resident for shoes because the
resident received Hospice services.
During an interview conducted on 4/23/19, at 12:39 P.M., CNA X said the resident often
complained of foot pain. He/she would tell staff to be careful, his/her feet were tender
he/she would say he/she needed a physician to check his/her feet. The CNA did not report
the resident’s complaints of foot pain to the nurses because the nurses were already aware
of the resident’s foot pain. The CNA did not know specifically how the nurses knew,
however, the nurses kept up on things regarding the residents. The resident complaints of
foot pain was not new. The CNA started working with the resident around (MONTH) (YEAR).
The first time he/she observed the resident’s feet, he/she was surprised by the color
(reddish blue), the temperature (cool to touch) and the amount of swelling. This was a
regular issue for the resident, at least for a few months.
During an interview conducted on 4/23/19, at 1:54 P.M., the administrator said the
podiatrist saw residents based on a list. Staff wrote a resident’s name on the list if the
resident was diabetic, if the resident requested to be seen or if nursing thought the
resident needed seen. The podiatrist came to facility every three months to cut toenails
and to check for and treat callouses. When the resident first admitted to the facility,
he/she had several wounds on his/her feet, but they healed. The resident recently
discharge from Hospice, but when he/she received Hospice services, he/she could not see
the podiatrist because Hospice would not pay for it
Record review of the resident’s progress notes, from 1/2/19 to 4/23/19, showed no
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0687

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 30)
documentation regarding the condition of the resident’s feet or his/her complaints of foot
pain.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
transferred two residents (Resident #26 and #63) safely; the facility failed to assess and
implement new interventions to prevent falls for one resident (Resident #22); and the
facility filed to ensure staff were present in the dining rooms during meal times. A
sample of 20 residents was selected for review. The facility census was 84.
1. Record review of the facility’s policy titled Transfer Activities, dated (MONTH)
(YEAR), showed the following information:
-Brakes on wheelchair should be locked, foot pedals raised, and chair placed at an angle
at the side of the bed nearest resident’s unaffected side;
-Obtain assistance of another individual if necessary for safe transfer;
-If the resident is able to participate in the transfer, have resident place the
unaffected foot under the ankle on the affected side. If necessary, place unaffected foot
under the affected knee and slide down to the ankle. With the unaffected leg, lift or
wiggle the affected extremity over the side of the bed;
-With your knees flexed and your legs slightly apart, face the resident. Grasp the
resident around the waist, supporting his/her back and head. Rise to a standing position,
at a pre-arranged signal, by straightening your knees and supporting the resident’s knees.
Allow the resident to gain his/her balance before proceeding. Support the weak leg with
your knee if necessary;
-Depending on the amount of assistance required, the nurse may either support the resident
on his/her affected side or stand in front of the resident;
-Support may be provided by a waist belt;
-Do not support the resident under the arms as this prevents the resident from using
his/her unaffected extremity;
-Do not allow the resident to put arms around your neck.
Record review of the facility’s policy titled Gait Belt Use, dated (MONTH) (YEAR), showed
the following information:
-Assist resident to a sitting position;
-Apply belt to the resident’s waist, tighten to fit snugly with the buckle at the side;
-Face the resident;
-Bend knees and place hands around the gait belt on each side of the resident’s waist;
-Bring the resident to a standing position while straightening knees;
-After the resident is standing, the belt provides assistance stabilizing the turning the
resident.
Record review of Resident #63’s face sheet (basic information sheet) showed the following
information:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s baseline care plan, dated 3/28/19, showed the following
information:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
-Alert/cognitively intact;
-Required assistance of two staff for bed mobility, transfers, and toileting;
-Safety concerns included: fall risk, ambulation difficulties, unsteady/unsafe independent
transfers, balance/gait unsteady, muscle weakness, fatigue/endurance concerns;
-Manual wheelchair.
Record review of the resident’s admission Minimum Data Set (MDS), a federally mandated
comprehensive assessment instrument, completed by the facility staff, dated 4/2/19, showed
the following information:
-Entered facility on 3/26/19;
-Required extensive physical assistance, two or more staff, when transferring from bed,
chair, wheelchair, standing position;
-Walked only one or two times in room and required two or more staff for physical
assistance;
-Did not walk in hallways.
Record review of the resident’s care plan, last revised 4/3/19, showed the following
information:
-At risk for falls related to left sided neglect and [MEDICAL CONDITION] post-[MEDICAL
CONDITION] (left sided lack of awareness and weakness after a stroke), impaired safety
awareness, impaired mobility, general debility, and disease processes;
-Ensure positioned properly;
-Keep call light within reach in room;
-Keep needed items within easy reach.
During an interview on 04/17/19, at 11:36 A.M., the resident’s family member said staff
almost dropped the resident one day last week. While he/she was transferred, his/her chest
was at the level of bed before the staff got the resident safely onto the bed. The family
member said he/she was in the room during that transfer.
Observation on 04/17/19, at 6:41 P.M., showed Certified Nursing Assistant (CNA) S and CNA
R entered the resident’s room. CNA R assisted the resident to sit on the side of the bed.
The aides put shoes on the resident’s feet. The aides placed the gait belt on the
resident’s waist. The aides moved the wheelchair to the right side of the resident’s bed.
CNA S held and lifted under the resident’s arm and pants during the transfer. CNA R held
the gait belt and lifted under the resident’s arm. The aides assisted the resident to a
standing position. CNA S moved to the resident’s right side and CNA R moved to the
resident’s left side. They assisted the resident to pivot with his/her right foot, the bed
moved away from the resident and the aides as the transfer took place. CNA S said, don’t
move the bed, and CNA R said that he/she did not move it. At 6:48 P.M., CNA S said this is
taking entirely too long. The aides transferred the resident from the bed to the
wheelchair, with extensive assistance.
Observation on 04/18/19, at 10:00 A.M., showed CNA N and CNA A in the resident’s room. The
aides had the resident standing at the side of the bed, with staff on each side of the
resident. The two aides pivot transferred the resident to the recliner. The aides did not
have a gait belt on the resident’s waist during the transfer. The aides lifted the
resident under his/her arms during the transfer.
During an interview on 04/22/19, at 7:40 A.M., CNA N said he/she uses a gait belt for
everybody. The gait belt goes around the resident’s waist, especially if the resident had
any chest surgery and around the chest if the resident had any abdominal surgery. Staff
should never transfer a resident by holding under the arms. Staff should hold on to the
gait belt. If a resident is able, the resident can hold onto staff to help. Resident #63
is a two person transfer with gait belt, left side is weak, he/she is a pivot transfer,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
and requires one staff on each side.
During an interview on 04/22/19, at 8:36 A.M., CNA A said he/she would ask another staff
that had transferred a new resident before or get therapy to help with the transfer.
He/she did not know if there was somewhere to look for transfer plan. Resident #63 is a
two person extensive assistance with a gait belt put around the chest and hold gait belt
while lifting transfer. The resident can only bear full weight on one side. The resident
pivots on his/her good leg as much as he/she can. Sometimes, staff have to hold under the
resident’s arm to help steady the resident.
During an interview on 04/23/2019, at 1:53 P.M., the Director of Nursing (DON) said there
are specific orders for transfers with the Hoyer lift or sit to stand with two staff. If a
resident is new admission from the hospital then therapy will advise how much assistance a
resident needs. Usually therapy will make recommendations to restorative. B-Wing residents
that have been here a long time just continue the same type of transfers. During a
transfer the gait belt goes around the resident. Staff should be sure they are able to
hold gait belt with transfer and use proper body mechanics. The gait belt needs to be
tight enough to stay in place, but able to get hands under belt. Gait belt should be used
for anybody that requires assistance. Staff should not grab or pull under arms.
During an interview on 04/23/19, at 3:36 P.M., the administrator and the quality assurance
(QA) support nurse said staff should look at the care plan for how to transfer a resident.
All staff have access to the care plan. For a new admission, they try to look at the
hospital paperwork. Therapy completes an evaluation for transfer assistance needed and
therapy communicates pretty well with staff.
2. Record review of Resident #26’s face sheet showed the resident admitted to the facility
on [DATE]. The resident’s [DIAGNOSES REDACTED].
Record review of the resident’s annual MDS, dated [DATE], showed the following
information;
-Severe cognitive impairment;
-Required extensive assistance with bed mobility and transfers;
-Did not walk;
-Required supervision for locomotion throughout the facility;
-Not steady, only able to stabilize with human assistance;
-Used a wheelchair for mobility.
Record review of the resident’s care plan, updated 2/15/19, showed the following
information:
-The resident required assistance of one staff for all of his/her activities of daily
living due to weakness, impaired mobility and disease process, including transfers and
toileting;
-The resident was up in a wheelchair daily with assistance from one staff to transfer.
A observation on 4/17/19, at 7:39 P.M., showed CNA Q wheeled the resident into his/her
room to assist him/her to the bathroom. The resident stood up from his/her wheelchair; the
CNA did not lock the resident’s wheelchair brakes. The resident placed his/her hands on
the sink and stood up. He/she then walked into the bathroom, unassisted, using the sink
and wall to steady himself/herself. While the resident walked into the bathroom, the CNA
stood near the sink, watching the resident. He/she did not apply a gait belt around the
resident’s waist and did not assist the resident with the transfer.
An observation on 4/23/19, at 9:26 A.M., showed the DON and MDS Coordinator MM wheeled the
resident into his/her room. The DON and MDS Coordinator wheeled the resident to the
bathroom door and assisted the resident into the bathroom by placing one of their arms
underneath the resident’s armpit. The DON and MDS coordinator did not use a gait belt to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 33)
transfer the resident. After the resident finished toileting, the DON and MDS coordinator
assisted the resident to his/her wheelchair by placing one of their arms underneath the
resident’s armpit.
During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said staff should use a gait
belt when transferring a resident unless a nurse or physician instructed them otherwise.
If they were not supposed to use a gait belt, it would be documented in the resident’s
care plan. The resident required assistance of one staff for transfers but at times,
he/she transferred himself/herself without assistance.
During an interview conducted on 4/22/19, at 9:15 P.M., CNA Q said the following:
-The resident required limited assistance from staff to transfer for balance, especially
with transfers from his/her bed to the bathroom, and the toilet to his/her bed.
-The resident sometimes transferred himself/herself, which was scary because resident
could lose his/her balance;
-The resident stood, most of the time, unassisted, and he/she used the wall, and available
furniture, to keep his/her balance;
-The CNA knew how a resident transferred by asking the resident what he/she could do.
Although the resident’s legs were strong, the resident had problems with balance;
-CNA Q used a gait belt every time he/she assisted a resident to transfer, if he/she had
one available, which he/she always did. If he/she did not have one with him/her, he/she
kept one at the nurses’ station;
-Last Wednesday (4/17/19), around 9:00 P.M., the CNA was checking on residents and found
Resident #26 sitting on the toilet. The resident transferred himself/herself. When the
resident finished, the CNA stood near the bathroom door talking to the resident. The
resident stood using the bathroom bar to steady himself/herself for a good couple of
minutes, then his/her legs buckled. The CNA rushed to the resident and caught him/her
before he/she fell to the ground. The resident did not have a gait belt on. The CNA told
the charge nurse of the resident’s almost fall, but he/she could not remember which charge
nurse he/she told.
During an interview conducted on 4/22/19, at 9:20 P.M., Registered Nurse (RN) J said
he/she knew how to transfer a resident by assessing the resident himself/herself. The
first time he/she assisted a resident to transfer, he/she had an aide with him/her to
assist if needed. Although you could ask a resident how he/she transferred, you could not
always take someone’s word on how he/she transferred. The RN worked the evening shift on
4/17/19. No staff told him/her Resident #26 almost fell .
During an interview conducted on 4/23/19, at 12:23 P.M., CNA K said he/she used a gait
belt if a resident was wobbly, he/she would not stand, or if he/she was not familiar with
the resident. All of the aides had a gait belt. Resident #26 transferred himself/herself.
He/she could stand and transfer to the toilet, but he/she needed staff assistance to wipe
and pull up his/her pants after he/she toileted.
During an interview conducted on 4/23/19, at 12:40 P.M., CNA X said Resident #26
transferred pretty well independently, but he/she needed assistance pulling up his/her
pants and he/she wanted someone to talk to. Staff used a gait belt to assist him/her
occasionally, depending on the day. Resident was sometimes unsteady and sometimes steady.
Staff should use a gait belt anytime they transferred a resident. If the aide did not know
the resident or did not know how that resident transferred, the aide either asked the
nurse or asked the resident if he/she could stand on his/her own, and did he/she use a
walker. These questions helped the aide to determine how much assistance the resident
needed. The first time CNA X transferred a resident, he/she had a second person with
him/her in care he/she needed assistance.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said staff
should use a gait belt any time they transferred a resident.
During an interview conducted on 4/23/19, at 3:38 P.M., the DON said staff should use a
gait belt with all transfers, especially if the resident needed assistance getting up. The
DON and MDS Coordinator MM should have used a gait belt to transfer Resident #26 to the
toilet.
3. Record review of Resident #22’s face sheet showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s fall risk assessment, dated 8/21/17, and completed by
facility staff, showed staff identified the resident to be at high risk for falls. (Staff
did not complete additional fall risk assessments after 8/21/17.)
Record review the resident’s nurses’ progress noted, dated 1/27/19, showed staff
documented the resident fell , hitting his/her left arm, and causing a three inch by one
inch skin tear with total skin loss. (Staff did not document a root cause of the fall, or
what new interventions were put in place.)
Record review of the resident’s quarterly Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff), dated 2/7/19 showed the following:
-Severely impaired cognition and vision;
-Extensive staff assistance of two required for transfers;
-Use of a chair alarm and bed alarm daily;
-Two or more non-injury falls since the previous assessment;
-The resident did not receive restorative or other therapy’s during the previous seven
days.
Record review the resident’s nurses’ progress notes showed the following:
-On 2/21/19, staff documented the resident fell with no apparent injury;
-On 3/20/19, staff documented the resident fell , hit his/her head, and caused an abrasion
to the top of his/her head;
-On 3/26/19, staff documented the resident fell injuring his/her left hand.
(Staff did not document a root cause of the fall, or what new interventions were put in
place.)
Record review of the resident’s left hand radiology (x-ray) report, dated 3/27/19, showed
an acute (sudden onset) fracture to the resident’s 5th finger (pinky).
Record review of the resident’s care plan, last reviewed date 3/27/19, showed the
following:
-Staff identified the resident as at risk for falls;
-Instructed staff to check on the resident frequently;
-Instructed staff to complete a fall risk assessment quarterly and as needed;
-Instructed staff to toilet the resident every morning then take the resident to the
nurse’s station.
During an interview on 4/22/19, at 8:15 A.M., the MDS Coordinator LL said the following:
-The residents’ care plans should be updated with every fall and additional interventions
should be added to prevent further falls;
-Resident #22 is very difficult because he/she is blind and impulsive. The resident had a
recent hand fracture and previous rib fractures related to falls;
-The charge nurse should complete a fall risk assessment quarterly and the MDS Coordinator
reviews the assessment when it is completed;
-Resident #22’s last fall risk assessment was completed on 8/21/17 which was the
resident’s admission assessment;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 35)
-The resident’s falls could be related to toileting. Staff should toilet the resident
every two hours and it should be addressed in the resident’s care plan.
During an interview on 4/22/19, at 11:00 A.M., Certified Nurse Assistant (CNA) A said
Resident #22 has had a lot of falls. The resident recently fractured his/her hand and has
fractured ribs in the past. Whenever the resident falls he/she is usually needing to
toilet or looking for something like cigarettes. The resident can ambulate, but is very
unsteady and will fall within a few steps. Staff should respond to the resident and not
the alarm. Staff have not been told to do anything different to prevent Resident #22’s
falls, just to monitor.
During an interview on 4/22/19 at 12:42 P.M., Licensed Practical Nurse (LPN) B said the
following:
-Dependent residents should be toileted every 2 hours;
-Resident #22 gets really agitated so staff just wait until he/she asks to go to the
bathroom;
-The resident will try to get up on his/her own and will fall. He/she has an alarm to let
staff know when the resident attempts to stand. The resident has had a lot of falls with
multiple abrasions and skin tears and a recent fracture to his/her left hand and previous
rib fractures;
-He/She is not aware of any new interventions put in place to prevent falls for Resident
#22. The only intervention is for staff to monitor the resident. The resident sits in the
dining room or nurses station all day so staff can see him/her.
During an interview on 4/22/19, at 1:11 P.M., the DON said she expects staff to toilet
dependent residents at least every two hours. The resident’s toileting needs should be
addressed in the resident’s care plan. The resident’s toileting needs puts them at risk
for falls. She expects staff to assess the resident after each fall and update the care
plan with interventions to prevent further falls.
4. An observation on 4/15/19, of the main dining room, showed the following information:
-At 11:30 A.M., staff served 24 residents their lunch trays. After staff served the
resident, they left the dining room;
-At 12:07 P.M., 16 residents ate their meal without staff present;
-At 12:20 P.M., eight residents remained in the dining room eating their meal. A staff
member entered the dining room, removed soiled clothing protectors from empty tables, then
left the dining room;
-At 12:27 P.M., two residents continued eating their meal, no staff present in the dining
room;
-At 12:33 P.M., the last resident finished his/her meal;
-At 12:34 P.M., the resident left the dining room.
During an interview conducted on 4/15/19, at 1:18 P.M., Resident #41 said staff did not
stay in the main dining room, especially for the evening meal. Sometimes, a supervisor or
aide might enter the dining room for a short time, but most of the time no one was in
there. This concerned Resident #41 because he/she witnessed a resident choke in the dining
room. No staff was in the dining room at the time so he/she had to find staff to help. The
resident asked staff why someone could not stay in the main dining room and staff told
him/her they did not have enough staff.
Observations on 4/17/19 showed the following information:
-At 5:17 P.M., staff finished serving residents’ meals and left dining room. Residents
continued to eat the evening meal without any staff present;
-At 5:31 P.M., two residents continue to eat their meals with no staff present in the
dining room.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 36)
During an interview conducted during the resident council meeting, on 4/17/19, at 9:57
A.M., the residents said the following information:
-Ten residents attended the resident council meeting. All ten residents ate their meals in
the main dining room. All ten residents said after staff served residents their meals they
left the dining room. Not only was there no staff supervision in case of a resident
emergency, there were no staff available to give residents more drinks or an alternate
meal if the resident did not like what staff served. The residents thought that after
kitchen staff plated their meals, they took a break. Several residents said they attempted
to get the attention of the kitchen staff by knocking on the door, but no one ever
answered;
-Resident #41 said after staff served the residents their meals, staff left the dining
room. This happens mostly in the evening and on the weekends. A few months ago, a resident
choked and LPN D had to perform the [MEDICATION NAME] maneuver. That resident now ate in
one of the assisted dining rooms.
During an interview conducted on 4/18/19, at 12:31 P.M., CNA Z said staff used to be
assigned to the main dining room during mealtime, but now staff are not assigned due to
the new schedule change.
During an interview conducted on 4/18/19, at 4:15 P.M., RN J said the residents who sit in
the main dining room ate without staff assistance. Residents, who required staff
assistance to eat, ate in the assisted dining room. Staff did not have to supervise the
main dining room, but he/she thought they should to assist residents and in case, a
resident choked. RN J did not think staff stayed in the main dining room for the entire
meal, they left after they served all the residents their meals
During an interview conducted on 4/19/19, at 12:00 P.M., CNA DD said if three Restorative
Nurses’ Aides (RNA) worked, one would go to each of the dining rooms (the main dining
room, A-wing assisted dining room and B-wing ding room). The charge nurse assigned staff
to the assisted dining rooms, but there was not always enough staff to assign to the main
dining room.
During an interview conducted on 4/22/19, at 3:31 P.M., CNA EE said usually two to three
aides assisted residents who ate in the assisted dining rooms and whoever was available
would supervise the main dining room.
During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said they, for
the most part, tried to ensure staff supervised residents’ meals in the main dining room.
Normally, restorative staff assisted in the main dining room and the department heads
assisted during the evening meal. Two RNAs worked from 6:00 A.M. to 2:00 P.M. and two RNAs
worked 2:00 P.M. to 6:00 P.M. Technically, the charge nurses did not assign staff to
supervise the main dining room, but if one of the restorative aides were not available,
the charge nurse should send one aide from the A-wing or B-wing to assist. A resident did
have a choking incident in the main dining room about 6 months ago.
During an interview conducted on 4/23/19, at 3:38 P.M., the DON said staff should
supervise and assist residents eating in main dining room. The RNAs should take turns on
assisting in the main dining room and if an RNA was not available, an aide should assist
and monitor residents. The RNAs knew to go to the dining room, but the charge nurses
needed to assign the aide.
5. Record review of Resident #26’s face sheet showed the resident admitted to the facility
on [DATE]. The resident’s [DIAGNOSES REDACTED].
Record review of the resident’s annual MDS, dated [DATE], showed the following
information;
-Severe cognitive impairment;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 37)
-Required extensive assistance with bed mobility and transfers;
-Did not walk;
-Required supervision for locomotion throughout the facility;
-Not steady, only able to stabilize with human assistance;
-Used a wheelchair for mobility.
Record review of the resident’s care plan, updated 2/15/19, showed the following
information:
-The resident required assistance of one staff for all of his/her activities of daily
living due to weakness, impaired mobility and disease process, including transfers and
toileting;
-The resident was up in a wheelchair daily with assistance from one staff to transfer.
An observation on 4/17/19 07:39 PM CNA Q wheeled the resident into his/her room to assist
him/her to the bathroom. The resident stood up from his/her wheelchair; the CNA did not
lock the resident’s wheelchair brakes. The resident placed his/her hands on the sink and
stood up. He/she then walked into the bathroom, unassisted, using the sink and wall to
steady himself/herself. While the resident walked into the bathroom, the CNA stood near
the sink, watching the resident. He/she did not apply a gait belt around the resident’s
waist and did not assist the resident with the transfer.
An observation on 4/23/19, at 9:26 A.M., the DON and MDS coordinator MM wheeled the
resident into his/her room. The DON and MDS coordinator wheeled the resident to the
bathroom door and assisted the resident into the bathroom by placing one of their arms
underneath the resident’s armpit. The DON and MDS coordinator did not use a gait belt to
transfer the resident. After the resident finished toileting, the DON and MDS coordinator
again assisted the resident to his/her wheelchair by placing one of their arms underneath
the resident’s armpit.
During an interview conducted on 4/22/19, at 9:58 A.M., CNA Y said staff should use a gait
belt when transferring a resident unless a nurse or physician instructed them otherwise.
If they were not supposed to use a gait belt, it would be documented in the resident’s
care plan. The resident required assistance of one staff for transfers but at times,
he/she transferred himself/herself without assistance.
During an interview conducted on 4/22/19, at 9:15 P.M., CNA Q said the following:
-The resident required limited assistance from staff to transfer for balance, especially
with transfers from his/her bed to the bathroom, and the toilet to his/her bed.
-The resident sometimes transferred himself/herself, which was scary because resident
could lose his/her balance.
-The resident stood, most of the time, unassisted, and he/she used the wall, and available
furniture, to keep his/her balance.
-The CNA knew how a resident transferred by asking the resident what he/she could do.
Resident #26 looked frail and you would think he/she was unable to walk, but if you looked
at his/her legs, you could see they were not atrophied (muscle loss due to underuse) at
all, his/her legs were still strong. Although the resident’s legs were strong, the
resident had problems with balance.
-CNA Q used a gait belt every time he/she assisted a resident to transfer, if he/she had
one available, which he/she always did. If he/she did not have one with him/her, he/she
kept one at the nurses’ station.
-Last Wednesday (4/17/19), around 9:00 P.M., the CNA was checking on residents and found
Resident #26 sitting on the toilet. The resident transferred himself/herself. When the
resident finished, the CNA stood near the bathroom door talking to the resident. The
resident stood using the bathroom bar to steady himself/herself for a good couple of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 38)
minutes, then his/her legs buckled. The CNA rushed to the resident and caught him/her
before he/she fell to the ground. The resident did not have a gait belt on. The CNA told
the charge nurse of the resident’s almost fall, but he/she could not remember which charge
nurse he/she told.
During an interview conducted on 4/22/19, at 9:20 P.M., RN J said he/she knew how to
transfer a resident by assessing the resident himself/herself. The first time he/she
assisted a resident to transfer, he/she had an aide with him/her to assist if needed.
Although you could ask a resident how he/she transferred, you could not always take
someone’s word on how he/she transferred. The RN worked the evening shift on 4/17/19. No
staff told him/her Resident #26 almost fell .
During an interview conducted on 4/23/19, at 12:23 P.M., CNA K said he/she used a gait
belt if a resident was wobbly, he/she would not stand, or if he/she was not familiar with
the resident. All of the aides had a gait belt. Resident #26 transferred himself/herself.
He/she could stand and transfer to the toilet but he/she needed staff assistance to wipe
and pull up his/her pants after he/she toileted.
During an interview conducted on 4/23/19, at 12:40 P.M., CNA X said Resident #26
transferred pretty well independently, but he/she needed assistance pulling up his/her
pants and he/she wanted someone to talk to. Staff used a gait belt to assist him/her
occasionally, depending on the day. Resident was sometimes unsteady and sometimes steady.
Staff should use a gait belt anytime they transferred a resident. If the aide did not know
the resident or did not know how that resident transferred, the aide either asked the
nurse or asked the resident if he/she could stand on his/her own, and did he/she use a
walker. These questions helped the aide to determine how much assistance the resident
needed. The first time CNA X transferred a resident, he/she had a second person with
him/her in care he/she needed assistance.
During an interview conducted on 4/23/19, at 1:54 P.M., the Administrator said staff
should use a gait belt any time they transferred a resident.
During an interview conducted on 4/23/19, at 3:38 P.M., the DON said staff should use a
gait belt with all transfers, especially if the resident needed assistance getting up. The
DON and MDS coordinator MM should have used a gait belt to transfer Resident #26 to the
toilet.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to assess and
implement a toileting plan and failed to provide incontinent care in manner that adhered
to infection control standards of practice for one resident (Resident #63) in a sample of
20 residents. The facility with a census of 84.
Record review of the facility’s policy, dated (MONTH) (YEAR), titled Toileting Plans for
Urinary Incontinence, showed the following information:
-Purpose of guideline is to provide guidance for the initiation and monitoring of and/or
toileting plan for the resident with urinary incontinence;
-Assessment included review the resident’s care plan to assess for any special needs of
the resident;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 39)
-Guidelines included options for managing urinary incontinence include primary toileting
plans and medication therapy;
-Types of programs, assess the resident for appropriateness of toileting plans being
considered;
-Bladder rehabilitation/bladder training may not be appropriate for the resident with
cognitive impairment or those who are frail or dependent on staff for assistance with
activities of daily living (ADLs);
-Incontinent management, if the resident does not respond and does not try to toilet, or
for those with such severe cognitive impairment that they cannot either point to an object
or say their own named, staff will use an incontinent management program;
-An incontinent management program involves checking the resident’s continence status at
regular intervals and providing incontinent care and garments as indicated by individual
need. The primary goals are to maintain dignity and comfort and to protect the skin.
1. Record review of Resident #63’s face sheet (basic information sheet) showed the
following information:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s baseline care plan, dated 3/28/19, showed the following
information:
-Alert/cognitively intact;
-Communicates verbally;
-Assist of two staff for toileting;
-Assist of one staff for hygiene;
-Sometimes incontinent of bowel;
-Sometimes incontinent of bladder;
-Bowel and bladder interventions included incontinence briefs or pads;
-Urinal within reach.
Record review of the resident’s bowel/bladder assessment, dated 3/28/19, showed the
following information:
-Occasionally bowel incontinence (one episode of bowel incontinence);
-Constipation not present;
-Occasionally incontinent of urine (less than 7 episodes of incontinence);
-No trial of toileting program attempted;
-Extensive assistance required for toilet use;
-Moderately cognitively impaired for daily decision-making;
-Resident usually aware of toileting needs;
-No redness noted to perineal (residents’ genitalia) and buttocks area;
-Contributing factors present:[MEDICAL CONDITION](stroke);
-Resident appeared to be good candidate for retraining;
-Will continue to work with therapy to build up strength.
Record review of the resident’s progress note dated 3/28/19, at 6:53 P.M., showed Licensed
Practical Nurse (LPN) M documented the resident up in the wheelchair, sitting in the
dining room. Therapy completed with assessment, resident will require two assist with
transfers and needed someone with him/her while using the commode due to resident leaning
backwards and unable to hold self in sitting position for a long period of time. Resident
able to make needs known to staff.
Record review of the resident’s admission Minimum Data Set (MDS – a federally mandated
comprehensive assessment instrument completed by facility staff), dated 4/2/19, showed the
following information:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 40)
-Required extensive assistance with bed mobility, transfers, toileting, and dressing;
-Occasional urine incontinence (less than seven episodes);
-Occasional bowel incontinence (less than one episode);
-Wheelchair required for mobility;
-Fall risk assessment showed moderate fall risk;
-No falls since admission.
Record review of the resident’s care plan, last revised 04/08/19, showed the following
information:
-Problem start date 03/26/19;
-At risk for complications related to incontinence of bowel and/or bladder;
-Give resident good pericare after each incontinent episode;
-Modify resident clothing as need to provide easy access to toilet;
-Observe for increased incontinence and report to the physician as needed;
-Observe for redness and breakdown in the perineal area when toileted;
-Observe for signs and symptoms of urinary tract infection [MEDICAL CONDITION] such as
fever, increased frequency of urination, hematuria, sediment in urine, cloudy or odorous
urine;
-Weekly skin assessments by licensed nurse.
During an interview on 04/16/19, at 2:43 P.M., the resident said he/she needed to go to
the bathroom, but did not want to tell anybody because he/she was in so much trouble.
During an interview on 04/17/19, at 11:21 A.M., the resident’s family member said staff
had not helped the resident to the bathroom at any time during visits and said he/she
visited with the resident every day for 3 to 4 hours and sometimes longer. The resident
wears diapers. He/she had not seen the resident be changed or diaper checked, or seen any
staff take the resident to the bathroom or offer a bedside commode during visits.
Observation on 04/17/19 showed the following:
-At 6:21 P.M., Registered Nurse (RN) V entered the resident’s room and checked the
resident for incontinence. The nurse said the resident was wet. RN V left the room;
-At 6:33 P.M., CNA S and CNA R entered the room, both put gloves on and pulled down the
resident’s pants. CNA S took trash bags out of his/her pocket. CNA R unfastened the
resident’s brief and rolled the resident to the side. The resident was incontinent of
bowel movement and urine. CNA S wiped the resident’s bottom and placed a new clean brief
under the resident (without performing hand hygiene or changing gloves). CNA R cleaned the
resident’s front area with a front and back, back and forth and around motion (potentially
introducing bacteria into the urinary tract). The aide fastened the brief and put the
resident’s pants back on;
-Staff did not offer to take the resident to the toilet or bedside commode.
Observation on 04/18/19, at 11:49 A.M., showed CNA A entered the resident room and closed
the door. The resident said he/she needed changed. CNA A had gloves on hands and put gait
belt on resident waist. CNA P entered the room, washed hands, and put gloves on hands. CNA
A prepared wash cloth, prepared trash bags and placed on empty bed. CNA P held gait belt
and had resident stand from recliner with extensive assistance from aide. CNA A pulled
resident’s pants down, removed the brief, wiped resident, disposed of the brief, wipes,
and gloves into the trash bag. CNA A placed new brief and pulled up the resident’s pants.
CNA A said the brief was dry, but changed it any way. The aides did not offer to take the
resident to the commode or urinal. CNA A and CNA P transferred the resident to the
wheelchair for lunch.
During an interview on 04/22/19, at 7:40 A.M., CNA N said the resident will let staff know
when he/she needed to go to the bathroom and when he/she wanted to lay down. When he/she
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 41)
notified staff of needs, the staff went to change and clean the resident. He/she had never
personally taken the resident to the bathroom. The resident will say he/she needs changed.

During an interview on 04/22/19, at 8:36 A.M., CNA A said the resident would let staff
know when he/she is wet, staff check the resident every two hours during night. It
required two staff to change the resident. Perineal care is completed each time. The aide
had not tried to get the resident to the toilet yet; wanted to make sure the resident
would be strong enough before attempting to use the toilet.
During an interview on 04/22/19, at 9:24 A.M., LPN O said that, in general, if a resident
is alert and oriented they will tell staff that they need to go to the bathroom, and some
are able to go to the bathroom on their own. Staff try to toilet incontinent residents
every two hours and always change them after breakfast. Staff change Resident #63 every
two hours, and he/she would also let you know when wet. If he/she pushes the call light,
the resident will say he/she needs changed. The resident wears a depend and staff should
offer to take him/her to the toilet. Usually, he/she was already wet when notifying staff.
He/she did not know if they take him/her to the toilet. They should offer, but he/she did
not know if the resident can sit on a toilet because the resident leans to the left side.
He/she would have to ask therapy if the resident can use the toilet.
During an interview on 04/23/19, at 1:53 P.M., the Director of Nursing (DON) said the
nurse complete clinical assessments on admission. It talks about incontinence status of a
resident. The nurses can document in the admission notes if a resident is continent or
not. She did not know for sure if there is bladder/bowel training. The charge nurse should
communicate with the aides regarding the plan for toileting or incontinent care. The aides
document in the kiosk what care they provide. Staff should probably by trying to toilet
the resident.
During an interview on 04/23/19, at 3:37 P.M., the administrator and quality assurance
(QA) support nurse said that on resident admission they really try to look at the care
plan from the hospital and initially the staff would assist residents based on what the
charge nurse tells them. Depending on the resident assessment they talk about it with the
resident and determine if they are able to accurately complete self-hygiene.

F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to monitor the
intake of, failed to consistently implement interventions for weight loss, and failed to
routinely provide set up and/or cueing assistance for one resident (Resident #63) with a
6.5% weight loss since admission. A sample of 20 residents was reviewed in a facility with
a census of 84.
Record review of the facility’s policy titled Meal Service, dated (MONTH) (YEAR), showed
the following information:
-Assist resident to a comfortable position;
-To encourage social interaction and mobility, all residents should be encouraged to eat
meals in the dining room, per facility guidelines;
-Serve tray of food to resident;
-Place all utensils and food containers within easy reach of the resident, assist as
necessary. Give as minimal assistance to resident as possible for their well-being. Teach

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 42)
and encourage use of adaptive equipment as necessary;
-Allow resident to enjoy his/her meal after you are sure adequate assistance provided;
-Return periodically to determine if the resident requires further assistance;
-Remove tray as appropriate area when the resident has finished eating, but do not rush
them;
-Take note of the percentage of food consumed.
1. Record review of Resident #63’s face sheet (basic information sheet) showed the
following information:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s care plan, problem start date of 3/26/19, showed the
following information:
-Encourage resident to have adequate hydration to promote skin integrity;
-Observe the resident’s nutritional status for weight loss and signs of dehydration;
-At risk for constipation related to decreased mobility, use of pain medications, and poor
dietary intake;
-Observe the resident’s dietary intake;
-Provide the resident with encouragement and gentle verbal cues;
-Set up trays at meals and assist the resident as needed.
Record review of the resident’s physician order [REDACTED].
-Order start date 3/26/19, for regular diet;
-Order start date of 3/26/19, for weigh monthly unless otherwise indicated;
-Order start date of 3/27/19, for speech language pathologist (SLP) to evaluate and treat
as indicated. SLP treatment five times a week for four weeks for dysphagia and cognitive
communication.
Record review of the resident’s nutrition preliminary/admission review, dated 3/27/19,
completed by the dietary manager, showed the following information:
-Weight 137 pounds;
-Current diet orders, to include supplements: regular diet;
-Staff did not document any food preferences/likes/dislikes/religious/cultural/ethnic food
needs;
-Location of most meals was in resident room;
-Independent in ability to eat/drink;
-New resident admitted with a regular diet, admission height 68 inches, weight 137 pounds.
Record review of the resident’s comprehensive nutrition initial assessment, dated 3/27/19,
completed by the registered dietitian (RD), showed the following information:
-[DIAGNOSES REDACTED].
-Current diet orders, including supplements: regular diet;
-The RD did not document any food preferences, likes/dislikes, religious/cultural/ethnic
food needs;
-Current weight of 137 pounds;
-Independent in ability to eat/drink;
-The RD did not document any oral problems, such as chewing problems;
-The RD documented the resident is a new admission with stroke diagnosis. The resident’s
weight was 137 pounds. Resident eats a regular diet by self. The resident is alert and
able to make wants known. Resident reports some trouble chewing chicken, but doesn’t want
meat ground up. Resident reports enjoying a cheeseburger at lunch today. Resident reports
likes Ensure (supplement) and agrees to an Ensure or other nutritious shake three times a
day with meals. The RD recommended Ensure or other nutritional shake three times a day
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 43)
with meals.
Record review of the resident’s baseline care plan (plan of care required to be completed
within 48 hours of admission), dated 3/28/19, showed the following information:
-Alert and cognitively intact;
-Disease management concerns included diabetic, high blood pressure, [MEDICAL CONDITION],
pneumonia, and post stroke;
-Staff did not identify any nutrition deficiency concern;
-Required set up for eating;
-Regular diet order;
-Boost supplement twice a day (breakfast and lunch);
-Dietary goal was to maintain weight through nutritional intake that is consistent with
preferences and overall health goals;
-Interventions included assess dietary preferences, monitor for safety and assist with
eating/drinking as needed.
Record review of the resident’s POS, dated 3/1/19 through 4/22/19, showed the following
information:
-An order, with a start date of 3/28/19, for Boost supplement twice a day, 8 A.M. and
12:00 P.M.
Record review of the resident’s progress notes, dated 3/28/19, showed new order received
for dietary supplements twice a day (breakfast and lunch) from the resident’s physician.
Staff entered new order into the computer system.
Record review of the resident’s medication administration history, dated 3/1/19 through
3/31/19, showed staff administered the Boost supplement twice a day as ordered, starting
on 3/28/19.
Record review of the resident’s POS, dated 3/1/19 through 4/22/19, showed the following
information:
-Order start date of 3/29/19, for snack three times a day between meals for [DIAGNOSES
REDACTED].
Record review of the resident’s progress note dated 3/29/19, at 12:20 P.M., showed the
resident in his/her room eating his/her meal. The resident required set up for meals.
Resident receiving physical therapy to strengthen his/her arms and legs. The resident able
to make needs known and had water within reach.
Record review of the medication administration history, dated 3/1/19 through 3/31/19,
showed the following information:
-Staff documented administration of the resident’s snacks three times a day between meals,
starting on 3/29/19.
Record review of the resident’s progress note dated 3/30/19, at 7:32 P.M., showed the
resident refused supper, but ate two other meals today and half eaten protein snack lay on
the bedside table.
Record review of the resident’s medication administration history, dated 3/1/19 through
3/31/19, showed the resident refused the 3/31/19, 10:00 A.M. and 2:00 P.M., snacks.
Record review of the resident’s progress note dated 3/31/19, at 8:55 P.M., showed the
resident’s appetite as fair. The resident enjoys snacking on the facility monster cookies
with protein.
Record review of the resident’s vitals report showed staff did not document meal intakes
for (MONTH) 2019.
Record review of the resident’s medication administration history, dated 4/1/19 through
4/23/19, showed staff documented the resident refused one snack on 4/1/19.
Record review of the weekly Resident at Risk (RAR) review dated 4/2/19, at 8:55 A.M.,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 44)
showed the resident admitted to the facility recently. RD consulted and recommended shakes
three times a day. Staff to continue to monitor.
Record review of the resident’s medication administration history, dated 4/1/19 through
4/23/19, showed the following information:
-Staff documented the resident refused two snacks on 4/3/19;
-Staff documented the resident refused two snacks on 4/4/19.
Record review of the resident’s progress note, dated 4/5/19, showed a RD recommendation
noted. Per the dietary director, the resident prefers Ensure and refuses to drink Boost at
this time. Family has provided Ensure until the facility supply arrives. A new order
received for Ensure three times a day with meals entered into the computer.
Record review of the resident’s POS, dated 3/1/19 through 4/22/19, showed the following
information:
-On 4/5/19, Boost supplement twice a day discontinued;
-Order start date of 4/5/19, for Ensure nutritional drink three times a day with meals per
RD recommendation.
Record review of the resident’s medication administration history, dated 4/1/19 through
4/23/19, showed the following information:
-Staff documented administration of the Boost supplement, twice a day, from 4/1/19 through
4/5/19.
Record review of the resident’s medication administration history, dated 4/1/19 through
4/23/19, showed the following information:
-Staff documented the resident refused one snack on 4/5/19;
-Staff documented the resident refused one snack on 4/6/19.
Record review of the resident’s care plan, revised 4/8/19, showed the following
information:
-Problem start date 4/8/19 of at risk for inadequate nutrition related to poor intake, and
disease process;
-Communicate with the resident’s family regarding any food and weight issues;
-Discuss likes and dislikes of food with resident;
-Encourage fluid intake;
-Give nutritional supplements as appropriate;
-Snacks as appropriate;
-Weigh the resident monthly and inform the physician of any significant changes.
Record review of the resident’s progress note dated 4/7/19, at 12:45 P.M., showed the
resident sitting up in bed, eating lunch at this time, visitor at bedside.
Record review of the resident’s medication administration history, dated 4/1/19 through
4/23/19, showed the following information:
-Staff documented the resident refused one snack on 4/7/19;
-Staff documented the resident refused one snack on 4/8/19.
Record review of the resident’s progress notes dated 4/9/19, at 8:31 A.M., showed the
weekly RAR review showed the resident has adjusted well to the facility. The resident to
be removed from weekly review.
Record review of the resident’s progress notes, dated 4/10/19, showed care plan meeting
completed. The resident attended the meeting and the resident’s weight remains stable.
Record review of the resident’s medication administration history, dated 4/1/19 through
4/23/19, showed staff documented the resident refused one snack on 4/11/19.
Record review of the resident’s vital report, showed staff documented the resident ate
26-50% of lunch on 4/11/19. Staff did not document any other meal intakes for (MONTH)
2019.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 45)
Record review of the resident’s medication administration history, dated 4/1/19 through
4/23/19, showed the following information:
-Staff documented the resident refused two snacks on 4/12/19;
-Staff documented the resident refused one snack on 4/13/19, 4/14/19, 4/15/19, and
4/16/19.
Record review of the progress notes, dated 4/16/19, showed the resident up in the
wheelchair for meals.
Record review of the resident’s vital signs, dated 4/16/19, showed the resident weighed
128 pounds (a 9 pound weight loss, 6.5% in three week time period).
Observation on 04/16/19 showed the following:
-At 12:21 P.M., the resident sat at the dining room table with water, milk, and coffee cup
for drinks;
-At 12:26 P.M., staff served the resident lunch. It included salad in a foam bowl, chili
in a regular bowl and hot dog on bun on regular plate. Staff placed the utensils on the
table and put the dressing on the salad and cut the hot dog into large bite size pieces.
The meal tray did not include an Ensure or Boost supplement;
-At 12:31 P.M., the resident ate the meal unassisted with his/her right hand, no staff
remained in the dining room for any assistance or supervision;
-At 12:48 P.M., the resident remained in the dining room, he/she ate less than one half of
the meal. The resident removed the clothing protector and his/her bottom dentures and set
them on the table;
-At 1:00 P.M., Licensed Practical Nurse (LPN) O pushed the resident in his/her wheelchair
to the resident room and stopped at the sink for the resident to rinse the bottom denture
and placed it in the denture cup. The nurse left the resident in front of the TV in the
resident room.
Observation on 04/17/19, at 8:16 A.M., showed the resident sat at the dining room table
and staff put butter and jelly on toast for the resident. Staff served the resident eggs,
sausage links, and a cup of juice. The meal tray did not include an Ensure or Boost
supplement. No staff remained in the dining room to assist or cue residents.
During an interview on 04/17/19, at 11:22 A.M., the resident’s family member said the
resident cannot cut up the food with one hand. The staff would leave the food without
cutting up meat. This past weekend was the first time a staff member had cut up the food
while the family member was there. This week was the first time the resident had been
required to go to the dining room. He/she had brought pizza to eat with the resident and
was told he/she could not do that because the resident had to go to the dining room for
meals. The family member said he/she has occasionally seen a small cookie given for a
snack but not every time he/she visited.
Observation on 04/17/19 showed the following:
-At 5:31 P.M., staff serving supper trays in the A wing assistive dining room. No staff in
the dining room supervising or cueing residents to eat. Certified Nursing Assistant (CNA)
R served meal trays and then left the A wing assistive dining room.
Observation on 04/17/19, at 5:37 P.M., showed a certified medication technician (CMT) left
the resident’s room. The CMT told the resident they will be bringing supper any time.
Observation on 04/17/19, at 5:58 P.M., showed the resident lay in bed. Staff had not
served the resident supper at that time.
Observation and interview on 04/17/19, at 6:21 P.M., showed the surveyor asked Registered
Nurse (RN) V about the resident’s supper tray or if the resident did not want a meal tray
or supper. RN V said, let’s go find out. The RN went to the resident’s room and asked
him/her if the resident did not want dinner. The resident said he/she did not get a meal
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 46)
tray. The RN notified a nurse aide. CNA S said the resident needed to get up in order to
have the meal. He/she said the resident needed to get up for the meal and the resident did
not want to leave his/her room, and the resident was required to eat in the dining room;
-At 6:24 P.M., the RN advised he/she would call the family member per the resident’s
request to sit with the resident as he/she ate in the resident room;
-At 6:27 P.M., the resident said the food is good, but he/she wanted to eat in his/her
room and would like to talk to the therapist about why he/she cannot eat in the room;
-At 6:41 P.M., the nurse aides transferred the resident to the wheelchair for supper. CNA
A said to RN V that the aides tried to get the resident up about 23 minutes to 5:00 P.M.,
but the resident wanted to eat in his/her room and did not want to get up. They did not
have two staff to get the resident up;
-At 6:48 P.M., RN V told the resident the family member will be in shortly to sit with the
resident while he/she eats in his/her room;
-At 7:13 P.M., the resident’s family member came to the nurses’ station and requested the
supper tray. The nurse said supper was a cold supper today, so do not have to re-heat. The
nurse gave the supper tray to the family member to take to the resident room. The staff
removed the milk from the supper tray to get a cold milk from the refrigerator. The meal
tray included a sandwich, cold salad, and milk. The meal tray did not include an Ensure or
Boost supplement;
-At 7:29 P.M., the resident ate the sandwich and the family member remained in the room.
Observation on 04/18/19, at 10:00 A.M., showed staff transferred the resident from the bed
to the recliner. The CNA asked if the resident would like a snack, the aide opened a honey
bun and gave it to the resident in the recliner, then left the room. The resident began to
eat the snack with no staff in the room.
Observation and interview on 04/18/19 showed the following:
-At 12:29 P.M., CNA A served the resident his/her lunch last in the dining room. The aide
asked the resident if he/she wanted salt and pepper and sprinkled salt and pepper on the
resident’s food. The resident had a bowl of chicken and dumplings, cornbread, okra, bowl
of oranges, cup of water, and cup of coffee. The meal tray did not include an Ensure or
Boost supplement. The resident began eating and drinking using his/her right hand to
crumble the cornbread into the chicken and dumplings. The resident stopped eating the
chicken and dumpling and cornbread and ate the oranges. The resident stopped eating and
began putting all the different food containers on his/her plate. Staff did not cue or
assist the resident to eat any additional food;
-At 12:41 P.M., the resident did not eat and continued to sit in the dining room;
-At 1:18 P.M., the administrator said she could wheel the resident to his/her room, but
would have to get help to transfer him/her. The administrator wheeled the resident into
his/her room. Staff did not offer any other option of food for the resident. Staff did not
attempted to cue or encourage the resident to eat any additional food;
-At 1:24 P.M., the resident sat in the wheelchair in room. The resident said lunch was no
good, hard okra, oranges ok, dumplings had weird taste.
Record review of the resident’s medication administration history, dated 4/1/19 through
4/23/19, showed the following information:
-Staff documented the resident refused two snacks on 4/21/19;
-Staff documented the resident refused two snacks on 4/23/19.
During an interview on 04/22/19, at 7:40 A.M., CNA N said the resident could eat with
his/her right hand but needed meal set up and should have somebody sitting at the table.
During an interview on 04/22/19, at 8:36 A.M., CNA A said the resident does pretty good
and eats by him/her self. Staff just make sure they have him/her in the dining room to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 47)
monitor for choking. The resident uses his/her one good arm to cut up the meat unless it
is really hard, then staff cut it up for him/her.
During an interview on 04/22/19, at 9:24 A.M., Licensed Practical Nurse (LPN) N said the
resident does need help to cut meat due to the left sided weakness, but once the meat is
cut up the resident can eat on his/her own.
During an interview on 4/23/19, at 10:34 A.M., CMT BB said the resident received house
shakes with meals and boost for snacks, he/she offered the boost when passing medications.
The resident took the shakes on occasion, but today he/she did not want the shake offered
for the morning snack and did not eat much for breakfast.
Observation on 04/23/19, at 12:25 P.M., showed the resident in bed with the head of bed
elevated almost 90 degrees. The bed level was in the high position. The resident said the
staff came and told him/her he/she had to get up for lunch. The resident said the
therapist had said he/she could have meals in his/her own room if the resident wanted.
Restorative therapy aide entered the resident room with the resident’s lunch tray. The
tray included a bottle of Ensure for the drink. The tray did not contain any other drinks.
The therapy aide said he/she was there to assist the resident to eat in his/her room
today.
During an interview on 04/23/19, at 10:02 A.M., the Dietary Manager said she looks at the
weight report every week and all weight loss is covered in RAR weekly meeting. When
indicated, residents are added to the dietitian weekly list, she usually comes on
Wednesday. Usually any resident with 7.5 %-10% weight loss or intake of less than 25% is
placed on the dietitian list. Anybody that is a high risk for nutrition concerns has meal
intakes reported in the main dining room. A-wing staff documents intake on all residents
and those are entered on each resident matrix. All residents in A and B wing need
assistance or cueing for meals. There are a couple of residents that eat on B wing because
they don’t like the larger dining room. The resident eats in his/her room most of the
time, and intake is usually 25 – 50%. The resident receives Ensure twice per day, at
breakfast and dinner. Nursing staff documents the Ensure and shake intakes under the
supplements. He/she is on the weight list as weight risk. Dietitian saw the resident on
3/27/19. The resident had a seven pound weight loss since admission. The resident weighed
130 pounds today and weighed 137 pounds on admission. The dietary manager added the
resident to the dietitian list to be seen tomorrow. The dietary manager said she did not
know if the resident needed assistance with meals. The resident receives super cereal at
breakfast because he/she requested sweetened cereal when first admitted to the facility.
So, the dietitian recommended super cereal.
During an interview on 4/23/19, at 10:34 A.M., CMT BB said supplement intakes are
documented under observations on the computer.
During an interview on 04/23/19, at 1:53 P.M., the Director of Nursing (DON) said she did
not know if the resident had weight loss, but will be sure he/she was listed on the RAR.
Diets are recommended by the RD and staff notify the physician to receive the orders for
the diet. Staff should be monitoring meal intake on every resident, especially if at risk
for weight loss.
During an interview on 04/23/19, at 3:36 P.M., the administrator and Quality Assurance
(QA) support nurse said the RD sees new residents every Wednesday. If a resident triggers
for weight loss, the dietary manager lets the RD know.

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe and appropriate respiratory care for a resident when needed.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
cleaned and maintained a continuous positive airway pressure ([MEDICAL CONDITION] –
treatment for [REDACTED]. for a [MEDICAL CONDITION], and failed to care plan the use of
the [MEDICAL CONDITION] for one resident (Resident #74) out of a sample of 20 residents.
The census was 84.
Record review of the facility’s policy titled, Continuous Positive Airway Pressure
([MEDICAL CONDITION]) Administration, dated (MONTH) 2019, showed the following:
-Check the physician’s order for pressure setting and method of administration;
-The [MEDICAL CONDITION] machine should be placed on the table near the bed;
-Fill the humidifier with water to the appropriate level;
-Assist the resident as needed with applying and adjusting the [MEDICAL CONDITION] mask
and head strap;
-Use a wet cloth or cleaning wipe to clean the outside surface of the [MEDICAL CONDITION]
machine;
-Clean the back filter weekly by running it under warm tap water;
-Replace the filter with a new one once a year;
-The tubing should be cleaned weekly:
-The mask and nasal pillows can be wiped with a damp cloth.
1. Record review of Resident #74’s face sheet (a document that gives a resident’s
information at a quick glance) showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s annual Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/10/18, showed the following:
-Cognitively intact;
-Limited staff assistance required for transfers;
-Use of a wheelchair for mobility;
-Respiratory treatment included a [MEDICAL CONDITION] machine.
Record review of the resident’s quarterly MDS, dated [DATE], showed staff did not document
use of a [MEDICAL CONDITION] machine.
Record review of the residents’ nurses’ progress note, dated 4/8/19, showed Licensed
Practical Nurse (LPN) D documented the resident was resting in the bed with the [MEDICAL
CONDITION] mask in place.
Record review of the resident’s care plan, last revised 4/9/19, showed staff did not care
plan interventions for the [MEDICAL CONDITION] machine use.
Record review of the resident’s (MONTH) 2019 physician order sheet (POS) showed no order
for a [MEDICAL CONDITION] machine.
Observation on 4/17/19, at 2:40 P.M., showed a [MEDICAL CONDITION] machine on the floor
next to the resident’s bed with the mask hanging from the side of the bed. The [MEDICAL
CONDITION] mask had a white film on it.
During an interview on 4/17/19, at 2:41 P.M., the resident said the following:
-He/She has had the [MEDICAL CONDITION] machine since admission to the facility;
-The facility staff has never cleaned the [MEDICAL CONDITION] machine since he/she has
been at the facility;
-He/She wishes staff would help him/her clean the [MEDICAL CONDITION] machine;
-He/She cleans the mask the best he/she can with a wet wipe after each use.
During an interview on 4/17/19, at 6:30 P.M., Certified Nurse Assistant (CNA) Q said
he/she does not know who cleans or takes care of the resident’s [MEDICAL CONDITION]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 49)
machines. He/She was never trained how to use or clean the [MEDICAL CONDITION] machines.
During an interview on 4/22/19, at 11:00 A.M., Certified Medication Technician (CMT) G
said the following:
-He/She is not sure who is responsible for cleaning and maintaining the resident’s
[MEDICAL CONDITION] machine;
-He/She assumes that it is not being done due to it not being documented on the resident’s
treatment administration record (TAR);
-If the [MEDICAL CONDITION] was being cleaned it should be documented on the TAR.
During an interview on 4/22/19, at 11:26 A.M., Licensed Practical Nurse (LPN) D said the
following:
-The evening shift nurse should be cleaning the resident’s [MEDICAL CONDITION] machine
once a week;
-The [MEDICAL CONDITION] machine cleaning should be documented on the resident’s TAR;
-He/She was unable to locate a physician’s order for the [MEDICAL CONDITION] machine or
documention on the resident’s TAR pertaining to the [MEDICAL CONDITION].
During an interview on 4/22/19, at 1:36 P.M., the Director of Nursing (DON) said the
following:
-He/She would expect there to be a physician’s order for the use of [REDACTED]
-The [MEDICAL CONDITION] machine should be cleaned weekly by nursing staff and documented
on the resident’s TAR and on the resident’s care plan;
– He/She does not know why there were no physician’s order for the resident’s [MEDICAL
CONDITION] or why it was not documented on the resident’s TAR.
During an interview on 4/22/19, at 2:42 P.M., Registered Nurse (RN) J said the following:
-He/She was not aware the resident used a [MEDICAL CONDITION] machine;
-The night nurse is supposed to clean the [MEDICAL CONDITION] machines weekly and it
should be documented on the resident’s TAR.
During an interview on 4/22/19, at 3:47 P.M., the Administrator said the following:
-He/She would expect a physician’s order for the [MEDICAL CONDITION] machine with the
appropriate settings to be in the resident’s chart;
-Nursing staff should clean the [MEDICAL CONDITION] machine and should document it on the
resident’s TAR;
-He/She would expect the [MEDICAL CONDITION] machine to be included in the resident’s care
plan.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to complete a bed
rail assessment, to include a risk/benefit review and alternatives attempted prior to the
use of bed rails; failed to document ongoing assessments of bed rails; failed to obtain
informed consents for side rails; failed to complete a bed rail safety check and regular
inspections of the bed frame and bed rails for risk of entrapment; and failed to develop
care plan interventions and approaches for the use of bed rails for two residents
(Resident #20 and #63) out of a sample of 20 residents reviewed. The facility census was

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 50)
84.
Record review of the facility’s policy titled, Bed Rail Policy, dated (YEAR), showed the
following:
-The objective of the policy is to determine if resident use is safe and appropriate;
-It is the policy of the facility to prevent entrapment and other safety hazards
associated with bed rail use;
-The facility’s leadership will be responsible for completing individual bed rail
evaluations on a regular basis, providing employees appropriate education related to the
risks and benefits of bed rail usage, and education pertaining to specific risks and care
needs associated with bed rail use;
– Before admission, prospective residents will be screened to help determine if care needs
necessitate the use for bed rails;
-Upon admission, readmission or change in condition, residents will be assessed for the
need of bed rails, including identifying an appropriate alternate prior to installation;
-The resident will be assessed for risk of entrapment prior to installation;
-The facility staff will document the bed rail is the least restrictive alternative for
the least amount of time;
-The facility staff will document the ongoing need for the bed rail;
-The facility staff will review the risk and benefits with the resident and resident
representative and obtain informed consent;
-There will be a physician order [REDACTED].>-The resident’s care plan will include use
of the bed rails as assessed;
-When installing or maintaining bedrails, the maintenance department staff will follow the
manufacturer’s recommendations and specifications;
-The maintenance department will conduct regular inspection of bed frames, mattresses, and
bedrails, as part of a regular maintenance program to identify areas of possible
entrapment.
1. Record review of Resident #20’s face sheet (a document that gives a resident’s
information at a quick glance) showed the following:
-Readmission date of [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/4/19, showed the following:
-Moderately impaired cognition;
-Extensive staff assistance required for transfers and bed mobility;
-Use of a wheelchair.
Observation on 4/16/19, at 8:56 A.M., showed the resident’s bed with a quarter bed rail on
both sides of the bed in the up position.
Record review of the resident’s (MONTH) 2019 physician order [REDACTED].
Record review of the resident’s care plan, review dated 2/4/19, showed staff did not care
plan the use of bed rails.
Record review of the resident’s medical record, on 4/22/19, showed the record did not
include the following:
-A bed rail assessment/evaluation;
-A bed rail consent form;
-A bed rail safety check form or completion of a regular inspection of the bed frame or
bed rails.
During an interview on 4/22/19, at 11:00 A.M., Certified Medication Technician (CMT) G
said the resident uses the side rails to get in and out of bed.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 51)
During an interview on 4/23/19, at 11:59 A.M., the administrator said the following she
could not find side rail assessments or signed consent forms for the resident.
During an interview on 4/23/19, at 12:28 P.M., the resident said the following:
-He/She uses the bed rails to get in and out of the bed;
-The facility got him/her a new bed frame and the side rails were already on it.
2. Record review of Resident #63’s face sheet showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s admission MDS, dated [DATE], showed the following
information:
-Required extensive assistance with bed mobility, transfers, toileting, and dressing;
-Wheelchair required for mobility;
-Fall risk assessment showed moderate fall risk;
-No falls since admission;
-Staff did not document the use of side rails.
Observation on 4/23/19, at 12:25 P.M., showed the head of bed elevated to almost 90
degrees, round side rails on both sides of the resident’s bed in the up position.
Record review of the resident’s care plan, last revised 04/08/19, showed staff did not
care plan the use of side rails.
Record review of the resident’s (MONTH) to (MONTH) 2019 POS showed no order for side rails
in place.
Record review of the resident’s medical record showed the record did not include the
following:
-Bed rail assessment/evaluation;
-Bed rail consent form;
-Bed rail safety check form or completion of a regular inspection of the bed frame or bed
rails.
During an interview on 4/23/19, at 12:25 P.M., the resident said the bed rails had been on
the bed since he/she arrived to the facility. The staff tied the call light on the left
side rail and he/she could usually reach it there. The left rail stayed up, but staff
would put the right side rail up and down when they provided cares to him/her. The
resident would hold on to the rails when staff rolled him/her to the side.
During an interview on 4/23/19, at 11:59 A.M., the administrator said she could not find
side rail assessments or signed consent forms for the resident.
3. During an interview on 4/22/19, at 11:00 A.M., Certified Nurse Aide (CNA) A said the
following:
-Side rails can be considered a restraint;
-Residents should be assessed for the use of side rails.
4. During an interview on 4/22/19, at 11:26 A.M., Licensed Practical Nurse (LPN) D said
the following:
-Residents should be assessed for the use of side rails;
-The assessment is used to evaluate if side rails are appropriate for the resident.
5. During an interview on 4/23/19, at 11:57 A.M., the Director of Nursing (DON) said
he/she did not know for sure what was expected in regards to the use of side rails with
residents.
6. During an interview on 4/23/19, at 11:59 A.M., the Quality Assurance Nurse said the
following:
-If a resident is using a side rail there should be an assessment completed to assess the
need and if the bed rail is a hazard;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 52)
-There should be a consent form signed by the resident or resident’s representative in the
chart.
7. During an interview on 4/23/19, at 11:59 A.M., the administrator said the following:
-The facility is currently not completing assessments or reassessing the use of side rails
with residents;
-A side rail assessment should be completed to ensure that the bed rail will not be a
hazard or may cause entrapment;
-The previous DON was responsible for completing assessments and measuring to ensure
safety with side rails.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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.

Based on observation and interview, the facility failed to store drugs and biologicals in
a locked storage area to ensure drugs and biologicals were inaccessible to unauthorized
staff and residents. The facility census was 84.
Record review of facility’s medication storage policy, dated (MONTH) (YEAR), showed the
following:
-An unattended medication cart must remain locked at all times;
-In the event the nurse is distracted from the task of passing medications by some
unforeseen occurrence, the cart must be locked before leaving it, or secured in a locked
medication room.
1. Observations on 4/16/19, from 2:51 P.M. until 3:18 P.M., showed the a nurses’
medication cart on A wing unlocked and not directly supervised.
Observations on 4/17/19, at 5:14 P.M., showed the nurses’ medication cart unlocked and not
directly supervised in the hallway next to the main dining room while the nurse was
administering medication to residents in the main dining room. The nurse was not in direct
line of sight of medication cart.
Observations on 4/17/19, from 7:31 P.M. until 7:35 P.M., showed a medication cart located
between the B wing nurses’ station and the main dining room, unlocked and not directly
supervised while a nurse was in a resident room and another resident was in wheelchair
directly next to medication cart.
During an interview on 4/18/19, at 4:20 P.M., with Registered Nurse (RN) J said medication
carts should be locked anytime staff are away from the medication cart.
During an interview on 4/23/19 at 12:49 P.M. with LPN (D), said medication carts should be
locked when not with it.
During an interview on 4/23/19, at 1:54 P.M. the Administrator said the medication cart
should be locked every time staff walk away.
During an interview on 4/23/19, at 3:38 P.M., the Director of Nursing (DON) said
medication carts should be locked at all times when staff are not with the cart.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Based on observation, interview, and record review, the facility failed to store food in a
sanitary manner when staff failed to store food in sealed, dated, and labeled
packaging/containers in the refrigerator and freezer. The facility census was 84.
1. Record review of the 2013 Missouri Food Code showed the following:
-Refrigerated, ready-to-eat, potentially hazardous food, prepared and packaged by a food
processing plant shall be clearly marked, at the time the original container is opened in
a food establishment and if the food is held for more than twenty four (24) hours, to
indicate the date or day by which the food shall be consumed on the premises, sold, or
discarded, based on the temperature and time combinations specified.
Record review of the facility’s policy titled, Receiving and Storage of Food, dated
(MONTH) 2011, showed the following:
-The dining services manager is responsible for receiving and storing food and nonfood
items;
-Keep all foods in clean, undamaged wrappers or packages. Reseal packages effectively.
Observations on 4/15/19, at 12:19 P.M., of the kitchen walk-in refrigerator showed the
following:
-An unsealed container of tomato juice, a bag of 13 hot dogs, and a container of 12
hard-boiled eggs undated and unsealed;
-White liquid substance not dated or labeled;
-Two undated and unlabeled packages of meat thawing in the refrigerator.
Observations on 4/15/19, at 12:30 P.M., of the kitchen walk-in freezer showed an unsealed
bag of approximately 15 chicken breast. Staff did not date or label the bag.
During an interview on 4/17/19, at 6:24 P.M., with Dietary Aide (DA) H said the following:
-All food should be dated when it is opened or put into a different package;
-All food should be in a sealed containers.
During an interview on 4/22/19, at 9:16 A.M., the Dietary Manager (DM) said the following:
-Any repackaged or open food should be dated and labeled with the date it is opened;
-All food should be kept in sealed containers/bags to prevent contamination.
During an interview on 4/22/19. at 3:53 P.M., the Administrator said the following:
-He/She would expect staff to label and date foods when opened;
-He/she would expect staff to keep food containers closed and sealed.

F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide or get specialized rehabilitative services as required for a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide physician ordered
rehabilitative services for one resident (Resident #74) out of a sample of 20 residents.
The facility census was 84.
1. Record review of Resident #74’s face sheet (a document that gives a resident’s
information at a quick glance) showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].), diabetes, and major [MEDICAL CONDITION] (mental health disorder
characterized by persistently depressed mood or loss of interest in activities, causing
significant impairment in daily life).
Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/2/19, showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 54)
-Cognitively intact;
-Limited staff assistance required for transfers;
-Extensive staff assistance required for toileting;
-Resident did not receive therapy in the previous seven days;
-Use of a wheelchair for mobility.
Record review of the resident’s care plan, last revised on 4/9/19, showed the following:
-Identified the resident as at risk for falls due to impaired mobility, weakness, and
disease process;
-Provide two staff for transfers due to a fall on 7/19/18;
-Provide assistance of one to two staff for activities for daily living (ADL – dressing,
grooming, bathing, eating, and toileting) due to impaired mobility, weakness, and disease
process.
Record review of the residents’ physician’s note, dated 4/10/19, showed the following:
-The resident has a tremor and does not know why;
-The resident is reporting leg weakness and short-term memory loss;
-Recommendation of physical therapy, occupational therapy, and speech therapy to address
the resident’s physical inability and short-term memory loss.
Record review of the resident’s physician order, dated 4/10/19. showed direction for
occupational therapy, physical therapy, and speech therapy to evaluate and treat the
resident due to weakness.
Record review of the resident’s medical record showed staff did not complete occupational
therapy, physical therapy, or speech therapy evaluations.
During an interview on 4/17/19, at 2:37 P.M., the resident said the following;
-He/She wanted to be on therapy so he/she could get stronger and be more independent;
-He/She talked to the physician about getting therapy to get stronger;
-He/She is supposed to be getting therapy. but is not.
During an interview on 4/18/19, at 10:59 A.M., the Director of Rehabilitation (DOR) said
the following:
-Nursing staff notify therapy when there are new physician’s orders
[REDACTED].>-Resident #74 is not currently receiving therapy;
-He/She was not aware the resident’s physician ordered therapy.
During an interview on 4/22/19, at 11:26 A.M., Licensed Practical Nurse (LPN) D said the
following:
-He/she was not aware Resident #74 had a physician order [REDACTED].>-He/She checked
and confirmed there were physician order’s for occupational therapy, physical therapy, and
speech therapy;
-Therapy should have been notified of the physician’s therapy orders so the resident could
be evaluated.
During an interview on 4/22/19, at 1:36 P.M., the Director of Nursing (DON) said the
following:
-He/She would expect Resident #74 to be evaluated by therapy if there were physician
orders [REDACTED].>-He/She was not sure why the resident was not evaluated by therapy;
-Nursing staff should notify the DOR when the physician puts in therapy orders.
During an interview on 4/23/19, at 2:34 P.M., Registered Nurse (RN) J said the following:
-When the physician orders [REDACTED].
-He/She did not remember entering a therapy order for Resident #74 in the electronic chart
and did not give the order to therapy.
During an interview on 4/22/19, at 3:50 P.M., the Administrator said the following:
-There needs to be better communication with therapy to make sure residents get therapy as
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 55)
ordered by the physician;
-The nurse is expected to put the physician’s therapy orders into the resident’s chart and
then give the order to the DOR;
-Resident #74 should have been evaluated for therapy as the physician ordered.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to use appropriate
infection control procedures to prevent the spread of bacteria or other infections causing
contaminants when staff failed to properly disinfect glucometers (a device use to test
blood sugar (glucose) results) between resident use for one resident (Resident #70) and
failed to use appropriate hand hygiene during blood sugar testing for two residents
(Resident #70 and Resident #35). The facility failed to provide personal care for two
residents (Resident #63 and Resident #28) in a manner that prevented potential
contamination and infection. The facility census was 84.
1. Record review of the Centers for Disease Control and Prevention (CDC) guidelines showed
blood glucometers approved for use for more than one person must be cleaned and
disinfected between each use.
Record review of the facility’s policy titled, Diabetic Infection Control, dated (MONTH)
(YEAR), showed the following:
-Multiple resident use glucometers will be cleaned and disinfected after each use using a
disinfectant wipe according to the container label;
-Gloves are to be worn when performing fingersticks and changed between resident contact;
-Remove and discard gloves after each fingerstick blood sampling;
-Perform hand hygiene immediately after removal of gloves.
2. Record review of Resident #70’s medical record showed an admission date of [DATE] and a
[DIAGNOSES REDACTED].
Observations on 4/17/19, at 8:26 A.M., showed Licensed Practical Nurse (LPN) D exited a
resident’s room holding a glucometer and removed a glucometer test strip. He/She laid the
glucometer on the top of the medication cart. No disinfectant wipes were available on the
medication cart. The nurse washed his/her hands, donned gloves, and inserted a glucometer
test strip. The LPN did not clean or disinfect the glucometer. The LPN entered Resident
#70’s room, laid the glucometer directly on the resident’s over the bed table and
performed the resident’s fingerstick. The LPN left the room, did not remove the possibly
contaminated gloves or wash his/her hands. The LPN placed the glucometer on top of the
medication cart, typed the glucose reading into the computer key board while wearing the
soiled gloves, then removed his/her gloves and washed his/her hands.
3. Record review of Resident #35’s medical record showed an admission date of [DATE] and a
[DIAGNOSES REDACTED].
Observations on 4/17/19, at 8:46 A.M., showed LPN D obtained a container of disinfectant
wipes at the nurse’s station area. The LPN returned to the medication cart and donned
gloves. The LPN did not wash his/her hands and wrapped the glucometer in a disinfectant
wipe. The LPN opened the glucose test strip bottle, pulled out a test strip, and inserted
it into the glucometer. The LPN entered Resident #35’s room, laid the glucometer on the
sink cabinet and performed the resident’s fingerstick. The LPN laid the glucometer on the
sink cabinet and wiped blood from the resident’s finger. LPN D picked up the glucometer,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 56)
returned to the medication cart wearing the same gloves and placed the possibly
contaminated glucometer on top of the medication cart. The LPN did not clean or disinfect
the top of the medication cart.
4. During an interview on 4/22/19, at 12:42 P.M., LPN B said the following:
-Glucometers should be cleaned with disinfectant wipes before and after each use;
-Staff should place a barrier underneath the glucometer if it is laid down in a resident’s
room;
-He/She said a nurse should wear gloves whenever cleaning the glucometer, then the gloves
should be removed and hand hygiene performed before obtaining a test strip from the
container and administering a glucometer test to a resident;
-Gloves should be removed and hands washed before leaving the residents room after
performing a fingerstick on a resident.
5. During an interview on 4/22/19, at 1:11 P.M., the Director of Nursing (DON) said the
following:
-She was not sure of the glucometer cleaning policy;
-Staff should be cleaning the glucometer with bleach and water every night;
-A barrier to lay the glucometer on would not be necessary whenever placing the glucometer
down in the resident’s room;
-She would expect staff to wash their hands before performing blood glucose tests. Gloves
should be removed and hands washed before leaving the resident’s room.
6. Record review of Resident #63’s face sheet (basic information sheet) showed the
following information:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s admission Minimum Data Set (MDS), a federally mandated
comprehensive assessment instrument completed by facility staff, dated 4/2/19, showed the
following information:
-Required extensive assistance with bed mobility, transfers, toileting, and dressing;
-Wheelchair required for mobility.
Observation on 04/17/19 showed the following:
-At 6:33 P.M., CNA S and CNA R left the resident room across the hall and had wipes in
hand. The aides entered the resident’s room. The aides washed their hands and pulled the
resident’s privacy curtain around the bed. The aides put on gloves. The aides prepared the
trash bag for soiled items. The aides pulled down the resident’s pants and placed the wet
pants in the bag. The aides assisted the resident to roll to his/her left side, CNA S used
wipes to clean the front. CNA R held the resident on his/her side. CNA S placed a new
incontinent brief under the resident and assisted the resident to roll back to the right
side. CNA R finished wiping the resident’s perineal region and sealed the trash bag;
-At 6:37 P.M., a staff member, with no name tag, entered the room and picked up the
resident’s cell phone and said he/she was taking the phone to call the resident’s family
member. The staff then returned to the room and said the call went to voice mail. The cell
phone rang as the aides finished dressing the resident. CNA S picked up the cell phone,
still wearing the same contaminated gloves, then handed the phone to CNA R, still wearing
the same contaminated gloves. CNA R removed one glove, but did not perform hand hygiene,
to answer the phone, but held the phone with the gloved hand first. The aide gave the
phone to the resident to talk to the family member;
-At 6:41 P.M., RN V entered the room with a shot. After administration of the shot, the
nurse took the resident’s cell phone with a gloved hand and the syringe in the same hand
and spoke with the resident’s family member. CNA S assisted the resident out of the bed;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 57)
-At 6:48 P.M., CNA S removed the bed linens and took the trash. CNA R placed a new trash
liner in the trash can.
-At 6:53 P.M., the aides left the room after washing their hands.
Observation on 04/18/19, at 11:49 A.M., showed CNA A entered the resident’s room, closed
the door, and the resident said he/she needed his/her diaper changed. CNA A wore gloves,
but did not use hand sanitizer or wash his/her hands in the resident room. The aide put
shoes on the resident, lowered the recliner leg rest, and placed a gait belt on the
resident’s waist. CNA P entered the room, washed hands at the sink, and put on gloves. CNA
A prepared the wash cloth and trash bags and placed them on the second bed in the room.
CNA P assisted the resident to stand, requiring extensive assistance. CNA A pulled down
the resident’s pants, and provided front perineal care. The aide threw the depends, wipes,
and gloves into the trash bag on the second bed. CNA A obtained a new pair of gloves, but
did not wash his/her hands or use hand sanitizer. CNA P continued holding the resident up
with the gait belt, CNA A placed a new depends on the resident and pulled up the
resident’s pants. The aides transferred the resident to the wheelchair. The aides placed
the wheelchair foot rests and wheelchair table for the left arm on the wheelchair. The
aides placed the resident’s glasses on the resident’s face. CNA A placed a full trash bag
on the recliner while plugging in the resident’s cell phone to charge. The aide took the
trash, removed his/her gloves and washed his/her hands at the sink as he/she left the
room.
7. Record review of Resident #28’s face sheet (basic information sheet) showed the
following information:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED]. organs), difficulty with walking, [MEDICAL CONDITION] (infection on
skin), rash and other non-specific skin eruption, multiple fractures of pelvis, history of
fracture of right humerus (right upper arm), and [MEDICATION NAME] (inflammation of the
digestive tract) due to [MEDICAL CONDITION] (bacterial infection in the colon).
Record review of the resident’s significant change MDS, dated [DATE], showed the following
information:
-Cognitively intact;
-Required extensive assistance for bed mobility, transfers, dressing, toilet use, and
personal hygiene;
-Always incontinent of bladder;
-Frequently incontinent of bowel;
-[DIAGNOSES REDACTED].
During an interview and observation on 04/15/19, at 1:38 P.M., the resident’s room had
isolation personal protective equipment (PPE) items in hall, including gowns and gloves in
a small three drawer plastic container. The resident said he/she had [MEDICAL CONDITION]
(an infection of the colon), said some staff wear gloves and some do not, the staff had
been wearing gowns but not any longer. The resident said he/she had only an occasionally
loose stool now, but did not know if he/she still had a [DIAGNOSES REDACTED].
Observation on 04/17/19, at 2:01 P.M., showed two nurse aides entered the resident room.
CNA S removed the resident’s top sheet and gown. The aide donned gloves and wiped the
resident’s face with bath wipes and wiped the oxygen tubing with the wipe. The aide placed
the resident’s gown and top sheet into the red biohazard containers. The aide placed the
wipes in a second red container. CNA R wiped down the resident table with wipes. CNA S
left the room. At 2:06 P.M., CNA S returned to the room with clean pillowcases and said
they would get the resident fresh water shortly. The aides left the room without washing
his/her hands or using hand sanitizer.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 58)
Observation on 04/18/19, at 10:12 A.M., showed CNA A entered the room and closed the door.
The aide removed the disposable meal items and placed them in a trash bag. The aide moved
the juice and coffee cup from the bedside table to the resident room sink. CNA A pulled
the privacy curtain. The aide applied gloves on his/her hands and removed the top sheet
and the resident’s incontinent brief. The aide provided perineal care for the resident.
CNA A changed gloves without washing hands. The aide assisted the resident to roll to the
right side to remove the wet brief and place a new brief under the resident. The aide
assisted the resident to roll to the left side and then to his/her back. The aide fastened
the new incontinent brief. The aide put a new gown on the resident. The aide changed
gloves without washing hands. With the potentially contaminated hands, the aide replaced
the pillows under the legs, and covered the resident with a top sheet. With potentially
contaminated hands, the aide raised the head of the bed, adjusted the nasal cannula for
the resident’s oxygen, and the pillow under the resident’s head.
8. During an interview on 4/22/19, at 1:11 P.M., the DON said the following:
-Gloves should be removed and hands washed before leaving the resident’s room;
-Touching items with soiled gloves would contaminate anything touched.

F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement policies and procedures for flu and pneumonia vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to offer the pneumococcal
vaccine (vaccines used to prevent some cases of pneumonia, meningitis (swelling of brain
and spinal cord membranes, typically caused by an infection), [MEDICAL CONDITION]
(potentially life-threatening complication of an infection)) to three residents (Resident
#6, #22, and #42) following the residents’ admission to the facility. The facility census
was 84.
According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine
Timing for Adults, dated 11/30/15, showed the following:
-Two pneumococcal vaccines are recommended for adults;
-CDC recommends vaccinations with the pneumococcal conjugate vaccine (PCV13 or Prevnar 13)
for all adults [AGE] years or older and people 19 through [AGE] years with certain medical
conditions, including chronic (ongoing) conditions;
-CDC recommends vaccination with the pneumococcal [MEDICATION NAME] vaccine (PPSV23 or
[MEDICATION NAME]) for all adults [AGE] years or older regardless of previous history of
vaccinations with pneumococcal vaccines, and people 19 to [AGE] years old with certain
medical conditions including chronic medical condition.
Record review of the facility’s policy titled Immunizations, dated (MONTH) 2012, showed
the following:
-Administration of the pneumococcal vaccines will be made in accordance with current CDC
recommendations;
-Give a dose of PCV13 to adults [AGE] years or older who have not previously received a
dose. Then administer a dose of PPSV23 at least one year later;
-If the resident already received one or more doses of PPSV23, give the dose of PCV13 at
least one year after they received the most recent dose of PPSV23.
1. Record review of Resident #6’s face sheet (a document that gives a resident’s
information at a quick glance) showed the following:
-admission date of [DATE];

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 59)
-[DIAGNOSES REDACTED].
-No known allergies [REDACTED].>Record review of the resident’s physician order, dated
8/22/16, showed instruction for staff to administer the pneumonia vaccine as needed unless
contraindicated or refused.
Record review of the resident’s immunization record, dated 10/21/16, showed staff
documented the resident received a PCV13. Staff did not document the resident received a
PPSV23.
Record review of the resident’s immunization consent or refusal form, dated 9/3/18, showed
the resident requested to be vaccinated with the PCV13 and the PPSV23.
During an interview on 4/17/19, at 11:25 A.M., the resident said he/she wanted to take the
pneumonia vaccines as recommended. He/She has [MEDICAL CONDITION] (one of the diseases
that comprises [MEDICAL CONDITION], with gradual damage of lung tissue) and uses oxygen
therapy at all times in order to breath. His/Her physician told him/her it is important
for him/her to take the vaccines.
2. Record review of Resident #22’s face sheet showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s immunization consent or refusal form, dated 8/21/17,
showed the resident’s responsible party requested the resident be vaccinated with the
PCV13 and the PPSV23.
Record review the resident’s immunization record, dated 8/21/17, showed staff documented
the following:
-The resident received a pneumonia vaccine about four years ago, and will need another
vaccine in the next year;
-No education material was provided;
-Staff did not document the type of pneumonia vaccine received or needed;
-Staff did not document further pneumonia vaccines administered.
3. Record review of Resident #42’s face sheet showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s immunization record, dated 1/1/13, showed the resident
received a PPSV23.
Record review of the resident’s immunization consent or refusal form, dated 3/5/19, showed
the influenza vaccine checked and the resident’s signature. The pneumonia section was
blank.
Record review of the resident’s physician order, dated 4/2/19, showed instruction for
staff to administer the pneumonia vaccine as needed unless contraindicated or refused.
During an interview on 4/18/19, at 10:30 A.M., Resident #42 said he/she did have one
pneumonia vaccine years ago. The facility staff have not offered or provided any education
on the pneumonia vaccine. He/She would like to receive all the recommended pneumonia
vaccines. He/She has respiratory problems and should take steps to prevent complications.
He/She has heart failure, [MEDICAL CONDITION], diabetes, and smokes cigarettes and
understands he/she is at risk for pneumonia.
4. During an interview on 4/19/19, at 8:26 A.M., Registered Nurse (RN) C said the facility
follows the CDC guidelines for pneumonia vaccines. All residents should be offered the
PCV13 and the PPSV23 and immunizations should be provided if the resident or responsible
party gives consent. Staff document the pneumonia vaccine on the resident’s preventive
health/immunization record.
5. During an interview on 4/22/19, at 9:00 A.M., Social Worker T said he/she provides the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265394

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

JORDAN CREEK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

910 SOUTH WEST AVE
SPRINGFIELD, MO 65802

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 60)
residents or their responsible party the pneumonia consent upon their admission. The
nurses follow-up and explain the risks and benefits of the vaccines and administer the
vaccines. The nurses track the vaccine due dates. He/She said the social workers should
review the consent form to assure they are complete.
6. During an interview on 4/22/19, at 12:42 P.M., Licensed Practical Nurse (LPN) B said
the social workers let the nurses know when a resident has consented for the pneumonia
vaccines and the nurse will administer the vaccine at that time. The nurse documents the
pneumonia vaccines on the preventative health/immunization record and adds the follow up
date on the resident’s Medication Administration Record [REDACTED]
7. During an interview on 4/22/19, at 1:11 P.M., the Director of Nursing (DON) said she
expects staff to follow the facility policy and CDC guidelines for pneumonia vaccines. The
residents should receive all vaccinations consented for unless the vaccine is
contraindicated.