Inspection Reports for
Jo Ellen Smith Convalescent Center

The investigation was complaint-driven, focusing on medication administration errors and failure to document blood sugar monitoring. The findings confirmed the complaints as substantiated.

The facility failed to ensure medications were administered per physician's orders for three residents and failed to document blood sugar levels for two residents as required by physician orders.

The visit was complaint-related, investigating allegations that medications were not administered timely. The complaint was substantiated based on medication administration audit reports and staff interviews confirming late administration.

The facility failed to ensure nursing staff administered medications timely as ordered by the physician for 2 of 3 sampled residents. Interviews with nursing staff confirmed medications were administered late beyond the prescribed times.

The facility failed to develop a care plan for a resident who smokes, did not properly program PEG tube feeding flush rates as ordered by the physician, and had discrepancies in controlled drug reconciliation for medication storage.

The complaint investigation focused on Resident #1's multiple falls and the facility's failure to implement requested fall prevention interventions. The complaint was substantiated based on observations and interviews confirming the lack of fall prevention measures.

The facility failed to ensure Resident #1 had appropriate fall prevention measures in place, including a mattress on the floor, non-skid socks, and call light within reach. Observations revealed slippery floors and lack of staff supervision in Resident #1's room, posing a safety risk.

The complaint investigation found that Resident #83 was not provided catheter care or monitored for urinary tract infection signs from 02/19/2024 to 03/04/2024. The Director of Nursing confirmed the lack of orders in the EMR until 03/05/2024 and absence of documentation.

The facility failed to ensure that Resident #83 with a Foley catheter was monitored for signs and symptoms of urinary tract infections and did not provide documented catheter care from 02/19/2024 to 03/04/2024. Physician orders for catheter care were not entered into the electronic medical record until 03/05/2024, and no documentation of catheter care or monitoring was found.

The investigation was triggered by a complaint regarding medication administration errors, including failure to provide prescribed eye ointment and failure to notify the physician timely. The complaint was substantiated with findings of medication unavailability and improper supervision during oral medication administration.

The facility failed to ensure a resident received prescribed medication due to pharmacy backorder and did not notify the physician promptly. Additionally, the facility failed to ensure oral medications were administered under direct supervision, as a nurse left medications unattended without verifying ingestion.

The facility failed to ensure meal intake was documented for each meal for 4 of 5 sampled residents with weight loss. Multiple dates across several months lacked meal intake documentation, and the facility could not provide evidence that meal intakes were monitored or documented for these residents.

The facility failed to ensure proper hand hygiene was performed by Certified Nursing Assistants, Licensed Practical Nurse, and Wound Care Nurse during incontinence care, catheter care, and wound treatment. Observations and interviews confirmed multiple instances of staff not performing hand hygiene before and after resident care activities.

The facility was found deficient in multiple areas including inaccurate resident code status documentation, failure to develop and implement comprehensive care plans, inadequate care plan meetings with residents, failure to provide proper assistance with activities of daily living, expired medications on medication carts, incomplete controlled substance reconciliation, and failure to follow infection prevention protocols during incontinence care.