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
- 25
- 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.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
Trusted data from CMS and state health departments
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