Jo Ellen Smith Convalescent Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 4502 General Meyer Avenue, New Orleans, Louisiana 70131
- CMS Provider Number
- 195204
- Inspections on file
- 26
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Jo Ellen Smith Convalescent Center during CMS and state inspections, most recent first.
The facility failed to ensure antidiabetic medications were administered per physician orders for three residents with diabetes. One resident with type 2 DM did not receive multiple ordered morning doses of Lantus insulin, as confirmed by eMAR review and an LPN interview. Another resident with diabetes mellitus without complications missed a scheduled weekly Ozempic injection, which the responsible LPN acknowledged was not given. A third resident with type 2 DM missed numerous ordered morning doses of Humulin 70/30 insulin, with two LPNs confirming they did not administer the medication on the identified days, and the DON confirming that all three residents should have received their medications as ordered.
The facility failed to properly document blood glucose monitoring for two residents with diabetes who had physician orders for routine blood sugar checks, including pre-meal testing and sliding-scale NovoLOG administration. Record reviews showed multiple instances where required blood sugar values were missing from the eMAR, even though LPNs later stated they had performed the tests but did not record the results. One resident also reported not having morning blood sugars checked as required, and the DON confirmed that the blood sugar levels should have been documented on the identified occasions.
Nursing staff did not administer medications within the required timeframe for two residents, resulting in multiple scheduled medications being given late. Facility policy requires medications to be given within one hour of the prescribed time, and staff confirmed that these delays were not in accordance with physician orders.
The facility failed to accurately reconcile and maintain controlled drugs on Med Cart A. A discrepancy was found in the narcotic count form, as Testosterone Cypionate Injection Solution was administered to a resident but not documented, and the vials were missing. Interviews confirmed inconsistencies in record-keeping, and the DON could not provide the necessary documentation for the missing vials.
A facility failed to develop a care plan for a resident with moderate cognitive impairment who was an active smoker, increasing the risk of smoking-related accidents. Interviews with the MDS Nurse and DON confirmed the absence of a necessary care plan to address smoking risks and interventions.
A resident with a PEG tube was not administered the prescribed water flush rate as ordered by the physician. The resident's PEG tube pump was programmed to deliver a water flush at 125 mL/hr every 4 hours instead of the ordered 130 mL/hr, resulting in a total of 750 mL instead of 780 mL over 24 hours. Staff interviews confirmed the discrepancy in the programming of the PEG tube pump.
A resident with a history of falls did not receive adequate care to prevent future falls. Despite a care plan requiring a call light within reach, non-skid socks, and a mattress on the floor, the resident experienced falls. Observations showed the room was warm with a slippery floor, and the resident was found without the required safety measures in place. The DON confirmed the absence of the mattress and acknowledged the slippery floor as a safety risk.
Failure to Administer Ordered Antidiabetic Medications as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders for three residents with diabetes. Resident #1 had an order for Lantus 26 units subcutaneously twice daily at 8:00 AM and 8:00 PM, starting 08/19/2025. Review of the December 2025 eMAR showed no documented evidence that the 8:00 AM Lantus dose was given on 12/11, 12/12, 12/16, 12/17, 12/18, 12/19, 12/22, and 12/25. The January 2026 eMAR likewise showed no documented evidence of the 8:00 AM Lantus dose on 01/01, 01/02, 01/05, 01/06, 01/08, and 01/12. In an interview, the LPN (S3) stated she did not administer Resident #1’s Lantus on the dates noted, and the DON (S1) confirmed that the Lantus had not been administered as ordered and should have been. Resident #2 had a diagnosis of diabetes mellitus without complications and a physician’s order for Ozempic 0.25 mg subcutaneously once weekly on Friday mornings, starting 12/12/2025. The January 2026 eMAR showed the Ozempic dose was not administered on the scheduled morning, 01/02/2026, and S3 LPN confirmed in interview that she did not administer the medication; S1 DON stated the resident should have received Ozempic as ordered. Resident #3, with type 2 diabetes mellitus, had an order for Humulin 70/30, 24 units subcutaneously at 8:00 AM before breakfast, starting 07/07/2024. The December 2025 eMAR showed no documented evidence that the 8:00 AM Humulin 70/30 dose was administered on 12/02, 12/05, 12/16, 12/17, 12/23, 12/26, 12/29, and 12/31, and the January 2026 eMAR showed missing administrations on 01/02, 01/05, 01/06, 01/07, and 01/14. S3 LPN stated she did not administer the Humulin 70/30 on the listed dates except 12/23/2025, and S6 LPN stated she did not administer it on 12/23/2025; S1 DON indicated Resident #3 should have received Humulin 70/30 as ordered.
Failure to Document Blood Glucose Monitoring for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to document blood sugar levels in accordance with physician orders and accepted professional standards for two residents with diabetes. Resident #1, who had moderate cognitive impairment and a diagnosis of type 2 diabetes, had a physician’s order to obtain blood sugar levels prior to meals starting on 12/17/2024. Review of the December 2025 and January 2026 Electronic Medication Administration Records (eMAR) showed no documented evidence that blood sugar levels were obtained on specific early morning dates and times, despite the order. Resident #1 reported not having his blood sugar checked in the mornings as required. An LPN later stated she had obtained Resident #1’s blood sugar levels on the identified dates but failed to document the results in the eMAR, and the Director of Nursing confirmed the lack of documentation. Resident #2, admitted with a diagnosis of diabetes mellitus without complication, had a physician’s order for NovoLOG insulin per a sliding scale, with parameters based on blood sugar levels obtained before meals and at bedtime. Review of Resident #2’s December 2025 and January 2026 eMARs revealed missing documentation of blood sugar levels on several specified dates and times. One LPN reported obtaining Resident #2’s blood sugar level on an identified evening but not documenting it in the eMAR, while another LPN reported obtaining blood sugar levels on two identified mornings but also failing to document them as required. The Director of Nursing indicated that Resident #2’s blood sugar levels should have been documented in the eMAR on those dates.
Failure to Administer Medications Timely as Ordered by Physician
Penalty
Summary
Nursing staff failed to administer medications in accordance with physician orders and facility policy for two of three sampled residents. The facility's policy requires medications to be administered within one hour of the prescribed time unless otherwise specified, and any deviations must be documented on the Medication Administration Record (MAR/eMAR) with the reason noted. For one resident, multiple medications including mirtazapine, melatonin, carvedilol, timoptic ophthalmic solution, and rosuvastatin were scheduled for administration at specific times but were instead given significantly late on several occasions, as confirmed by both the Assistant Director of Nursing and an LPN. Another resident also experienced delays in the administration of scheduled medications, including clonidine, senna, and diclofenac sodium, with doses given more than an hour past the scheduled times. Staff interviews confirmed that these medications were not administered timely as ordered by the physician. The facility's failure to ensure timely medication administration as per physician orders and policy was substantiated through record reviews and staff interviews.
Controlled Drug Reconciliation Failure on Med Cart A
Penalty
Summary
The facility failed to ensure that controlled drugs were accurately reconciled and maintained for one of the medication carts, Med Cart A, during a medication storage facility task. An observation on March 19, 2025, revealed a discrepancy in the narcotic count form for Med Cart A. Specifically, the form did not document the administration of Testosterone Cypionate Injection Solution 200 mg/mL to Resident #184, despite the EMAR indicating it was administered on March 5, 2025. Additionally, the two vials of the medication were not available for use on Med Cart A. Further review of the facility's records showed that the narcotic count form in the Med Cart A narcotic book indicated the availability of two vials of Testosterone Cypionate Injection Solution 200 mg/mL from March 1 to March 19, 2025, with no discrepancies noted. However, interviews with S3LPN and S2DON confirmed inconsistencies in reconciling the narcotic count form, and the two vials were administered by another nurse without proper documentation. S2DON could not provide the narcotic count form for the missing vials, highlighting a failure in maintaining accurate records for controlled substances.
Failure to Develop Smoking Risk Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan for a resident who was an active smoker, which is necessary to decrease the risk of smoking-related accidents. The resident, identified as having moderate cognitive impairment, was confirmed to be an active smoker through interviews and record reviews. Despite this, there was no documented evidence of a care plan addressing the risks and interventions associated with smoking. Interviews with the MDS Nurse and the Director of Nursing confirmed the absence of such a care plan, acknowledging that it should have been developed for the resident.
Failure to Administer PEG Tube Water Flush as Ordered
Penalty
Summary
The facility failed to administer a resident's PEG tube feeding water flush as ordered by the physician. Resident #104, who was admitted with diagnoses including cerebral infarction, dysphagia, and malnutrition, had a physician's order for a PEG tube feeding that included a water flush at a rate of 130 mL/hr every 4 hours. However, observations on multiple occasions revealed that the PEG tube pump was programmed to administer a water flush at a rate of 125 mL/hr every 4 hours, resulting in a total of 750 mL of water flush over 24 hours instead of the prescribed 780 mL. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the PEG tube feeding flush was not programmed according to the physician's order. The LPN acknowledged the discrepancy in the water flush rate, and the Director of Nursing confirmed that the flush should have been administered at the rate specified by the physician. This oversight in programming the PEG tube pump led to the deficiency identified during the survey.
Failure to Prevent Falls and Address Safety Hazards
Penalty
Summary
The facility failed to ensure that a resident with a history of falls received adequate care and services to prevent future falls. Resident #1, who required extensive assistance for bed mobility, transfers, and toilet use, had a care plan that included interventions such as keeping the call light within reach, ensuring the resident wore non-skid socks, and placing a mattress on the floor next to the bed. Despite these interventions, Resident #1 experienced two unwitnessed falls in their room. Observations revealed that the resident's room was warm, with a slippery floor due to a condensation-like substance, and the resident was found lying in bed without staff present, the call light out of reach, not wearing non-skid socks, and without a mattress on the floor. Interviews with the Director of Nursing (DON) confirmed that the family had requested a mattress be placed on the floor to prevent falls, but it was not present in the room. The DON acknowledged the slippery floor as a safety risk. Further observations showed the room remained warm and humid, with the same safety hazards present. The facility's failure to implement the care plan interventions and address the environmental hazards contributed to the deficiency in providing a safe environment for Resident #1.
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The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
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