Siloam Healthcare, LLC

Based on observation, record review and interview, the facility failed to ensure infection control measures, including hand hygiene, was performed, before entering a resident room on contact isolation, to prevent the spread and cross contamination, and potential infection, for 1 (Resident #91) of 1 sampled resident. The findings are: 1. Review of the Medical Diagnosis Record indicated the facility admitted Resident #91 with a diagnosis of diabetes mellitus. A review of Resident #91's Physician Orders, for the month of December 2023, revealed an order, dated 12/11/2023, for contact isolation as of 12/5/2023 for Vancomycin-resistant Enterococci (VRE) and Methicillin-Resistant Staphylococcus Aureus (MRSA). Review of Resident #91's Care Plan with an initiated date of 12/11/2023, revealed the resident required extensive assistance for activities of daily living (ADLs). On 12/11/23 04:29 PM, a sign outside Resident #91's room was observed and noted to read, Contact Isolation. A plastic cart outside Resident #91's room observed with personal protective equipment (PPE). Certified Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to maintain a safe, functional, sanitary, and homelike environment related to broken geriatric chairs, shower chairs, and door frames free of sharp, jagged edges, to prevent the potential injury and or spread of disease. The findings are: A review of the undated facility's Community Guide, revealed, Resident Rights, the residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. 1. A review of theMedical Diagnosis Record indicated the facility admitted Resident #72 with a diagnosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure 1 of 1 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen, and dietary staff washed their hands before handling clean equipment. These failed practices had the potential to affect 97 residents who received meals from the kitchen (total census: 97) as documented on a list provided by Dietary Supervisor on 9/8/22. The findings are: 1. On 9/6/22 at 11:50 AM, during the initial tour of the kitchen with the Dietary Supervisor, the following observations were made in the dry storage room. There were dated items in boxes and plastic containers on the shelves that did not indicate whether the date was the opened or received date. a. Parsley 8/22. b. Barbeque sauce individual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure resident call lights were in reach for residents to be able to notify staff of their needs for 1 of 1 (R#62) sample selected residents. This failed practice had the potential to affect all residents capable of using the call lights. The findings are: 1.Resident #62 had diagnoses of Transient Cerebral Ischemic Attack, Dementia, Atrial Fibrillation, Congestive Heart Failure, Weakness, & Pain. admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/12/2022 scored a 7 (0-7 severely cognitively impaired) and required supervision for bed mobility, transfers, & toilet use, and physical assistance for bathing. a. On 09/06/22 at 01:33 PM, R#62 attempted to get to call light attached approximately 5 1/2 feet off ground, on edge of curtain. R#62 stumbled back to the bed and surveyor introduced self. Surveyor asked why her call light was attached so high on the curtain. R#62 stated they told me it had to be there so both of us (pointing to roommate's bed) could reach it if we needed help. I just pushed it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to ensure a resident had the right to make a significant choice about his life in the facility to promote and facilitate self-determination for 1 (Resident #76) sampled selected resident. The findings are: 1. Resident #76 had diagnoses of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Presence of Automatic (Implantable) Cardiac Defibrillator, Chronic Obstructive Pulmonary Disease, Neuromuscular Dysfunction of Bladder, History of (Healed) Traumatic Fracture, Contracture of Right Hip and Acquired Absence of Right Leg Above Knee. A Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 08/22/22 indicated the resident received a score of 15 (suggests cognitively intact) on the Brief Interview for Mental Status [BIMS] and required Physical assistance of 1 for bathing, Limited assistance of 1 for bed mobility, transfer, dressing, toilet use and personal hygiene, was Independent after setting up for eating, had indwelling Foley catheter and was always continent of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure walls were in good repair, the courtyard decking was in good repair, and the facility was maintained a safe, clean, and sanitary environment. This failed practice had the potential to affect 99 residents according to the resident census and conditions provided by the Assistant Director of Nursing on 9/6/22. The findings are: 1. Resident #76 had diagnoses of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Presence of Automatic (Implantable) Cardiac Defibrillator, Chronic Obstructive Pulmonary Disease, Neuromuscular Dysfunction of Bladder, History of (Healed) Traumatic Fracture, Contracture of Right Hip and Acquired Absence of Right Leg Above Knee. A Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 08/22/22 indicated the resident received a score of 15 (suggests cognitively intact) on the Brief Interview for Mental Status [BIMS] and required Physical assistance of 1 for bathing, Limited assistance of 1 for bed mobility, transfer, dressing, toilet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop/implement a Comprehensive Care Plan to enable staff to properly care for residents for 2 of 2 (Resident 65 & 68) sample selected residents. This deficiency had the potential to affect 99 residents in facility per the Resident Census received from the Assistant Director of Nursing (ADON) 9/7/22 @ [at] 3:05 PM. The findings are: 1. Resident #65 had diagnoses of Pneumonia, Type 2 Diabetes Mellitus, B-cell Lymphoma, & Contact with and (suspected) exposure to Pediculosis, Acariasis, & other infestations. admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/13/2022 scored a 10 (8-12) moderate cognitive impairment) and required extensive 2-person physical assistance for bed mobility, & toilet use, extensive 1-person physical assistance for transfers, and supervision and set-up for eating. a. 09/10/22 02:15 PM Record review documented R #65 admitted on [DATE]. As of 9/9/22, the Comprehensive Care Plan dated 8/18/22 was incomplete,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were provided nail care for 3 (Resident #60, #237, and #73) of 24 sampled residents that required assistance with nail care according to a list provided by the Director of Nursing (DON) 9/9/22; and the facility failed to ensure showers or baths were provided as scheduled for 1 (Resident #3) of 21 (R2, R3, R4, R7, R9, R10, R12, R14, R17, R26, R27, R28, R29, R39, R41, R45, R47, R48, R50, R51, R55, R56, R59, R60, R62, R64, R65, R66, R68, R73, R75, R76, R77, R78, R138, R236, R237, & R238) sampled residents who required assistance for bathing according to the list provided by the DON 9/9/22 to promote good hygiene and prevent infections. The findings are: 1. Resident #60 had diagnoses of Alzheimer's disease with late onset and Dementia, unspecified severity. The Quarterly Minimum Data Set with an Assessment Reference Date of 8/8/22 documented the resident scored 0 (0-7 indicates severely impaired) on a Brief Interview for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing and/or nebulizers were dated and stored in a storage bag when not in use to prevent infections for 2 (Residents #238 and #59) of 8 sampled residents who had physician orders for oxygen and or updrafts according to a list provided by the Director of Nursing on 9/9/22. The findings are: 1. Resident #238 had diagnoses of Chronic Obstructive Pulmonary disease, (COPD), Malignant Neoplasm of unspecified part of right bronchus or lung, and Pulmonary Hypertension. The resident's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/9/22 was in progress and not yet completed. a. Physician orders documented, .9/3/22 Change, date and initial tubing and bottle and place in Ziploc bag every week on Sunday. Every night shifts every Sun for Change and date Change, date and initial tubing and bottle and place in Ziploc bag every week on Sunday; Oxygen every 1 hours as needed for Shortness of Breath Oxygen @ [at] 2-3 Liters/Nasal Canula as needed may remove per self for Activity of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record review the facility failed to ensure pain management was provided and pain medication was administered as ordered prior to wound care for 1 of 1 sampled resident (R#75). This failed practice had the potential to effect 1 resident receiving pain management prior to wound care. 1. Resident #75 had diagnoses of Pressure ulcer to left hip, stage 3, Pressure ulcer of contiguous site of back, buttock and hip, stage 4, Pressure ulcer of right hip, stage 4, Pressure ulcer of unspecified site, unstageable . The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/25/2022 documented the resident scored 14, on a Brief Interview for Mental Status (13-15 indicates cognitively intact) and requires limited assistance with bed mobility, toileting, dressing and personal care Activities of Daily Living (ADL)'s and bathing. a. Physician order dated 8/19/22 Morphine Sulfate IR tablet 15mg [milligrams], give 1 tablet by mouth as needed for one tablet po [by month] 30 minutes prior to dressing changes. b. On 9/7/22 at 9:24 AM, during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 7 residents who received pureed diets, 28 resident who received mechanical soft diets and 21 residents who received fortified foods from 1 of 1 kitchen (total census: 66) according to a list provided by the Dietary Supervisor on 9/08/22 The findings are: 1. On 9/08/22 at 11:30 AM, The following observations were made during the breakfast meal service: There were no fortified food items prepared for the residents on fortified foods. The residents were not served fortified foods at breakfast. 2. On 9/08/22, the menu for the lunch meal showed residents who received mechanical soft diets were to receive 3 oz (ounces) of ground hamburger patty; residents who received pureed diets were to receive # (number) 6 scoop of pureed hamburger meat (2/3 cup) and there was on meu available for fortified foods. 3. The following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure food was prepared by methods that maintained appearance; hot foods were served hot and cold foods were served cold to maintain palatability and encourage adequate nutritional intake for 2 of 2 meals observed on the 100 Hall, 200 Hall, and 300 Hall. The failed practice had the potential to affect 26 residents who received meal trays in their room on 100 Hall, 20 residents who received meal trays in their rooms on 200 Hall, 16 residents who received meal trays in their rooms on 300 Hall, as documented on a list provided by Assistant Dietary Supervisor on 9/09/2022 at AM. The findings are: 1. The facility mealtimes, documented on a form provided by the Administrator on 9/06/2022., were 7:00 a.m. for breakfast, 12:00 p.m. for lunch, and 5:00 p.m. for dinner. The form also documented, .Start service out within 15 minutes of the hour + [and] serve within 1 hour, 100 Hall, 200 Hall, 300 Hall, 400 Hall, Main Dining Area . 2. On 09/06/22 at 01:33 pm, Resident #62 attempted to get to call light. R #62 stated, I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 7 residents who received pureed diets as documented on the List Dietary Supervisor provided by the Food Service Supervisor on 9/8/2022. The findings are: 1. On 9/08/2022 at 7:06 AM, Dietary Employee #1 used a spoon to place 7 servings of mixed fruits into a blender and pureed. At 7:09 AM Dietary Employee #1 portioned pureed fruits into 7 bowls. The consistency of the pureed mixed fruits was chunky, not smooth. On 9/09/22 at 8:00 AM, the Surveyor asked Dietary Employee #1 to describe the consistency of the pureed mixed fruits. She stated, It was chunky. 2. On 9/08/2022 at 7:28 AM, The following items were on the steam table: a. A pan of pureed eggs was on the steam table. The consistency of the pureed eggs was not smooth. There were pieces of red pepper visible in the mixture. b. A pan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure residents' meals were consistently served at regularly scheduled times to provide residents with a dependable eating schedule for 1 of 1 meal service observed. The failed practice had the potential to affect all 97 residents who received meals from the kitchen (total census: 97), according to the list provided by the Dietary Supervisor dated 9/8/22. The findings are: 1. A Resident Council meeting on 6/6/22 showed, Meals always cold and Dinner not until 7pm. 2. The Grievance log of 8/2/22 showed, food was cold and late. 3. On 9/8/22 at 9:01 a.m., the last resident on 300 Hall was served. This was a period of 2 hours after the scheduled mealtime.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure COVID-19 screening of all person's entering facility was completed and failed to ensure employees were wearing source control masks appropriately covering both nose and mouth to help prevent the spread of COVID-19. This failed practice had the potential to affect 99 residents per facility resident Census received from Assistant Director of Nursing (ADON) on 9/7/22 @ [at] 3:05 PM. The findings are: 1. On 09/07/22 at 08:30 AM, the Administrator introduced herself to surveyors and stated she was ill and had a note to be out this week but would be here for the survey and available unless she got an appointment to see her ENT. Administrator had mask on face not covering nose and was coughing. a. On 09/08/22 at 03:31 PM, the Administrator observed in SSD office with mask below nose and coughing. The Surveyor entered room and Administrator left mask below nose during conversation. b. On 09/08/22 at 05:20 PM, the Administrator was in front…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on interview and record review, the facility failed to ensure COVID-19 vaccinations were provided in a timely manner to residents eligible to receive the vaccination to help prevent the spread of COVID-19. This failed practice had the potential to affect 47 residents eligible for COVID-19 Booster #2 and were over age [AGE], 4 residents eligible for COVID-19 Booster, and 1 resident eligible for COVID 2nd vaccination per facility resident COVID-19 vaccination list received from Infection Control & Preventionist (ICP) 9/08/22 @ [at] 10:09 AM. The findings are: 1. On 09/07/22 at 01:51 PM, Surveyor received resident COVID vaccination list from consultant. 2. On 09/07/22 at 09:30 PM, Surveyor reviewed resident list of COVID-19 vaccinations after noting that National Healthcare Safety Network [NHSN] reported 6% of residents were up to date. List of vaccinations from consultant only contained 82 residents. 3. On 09/08/22 at 08:40 AM, Surveyor informed Assistant Director of Nursing (ADON) that Resident COVID…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the admission nursing assessment was documented completely to create a baseline care plan to enable staff to properly care for residents for 1 of 1 of 1 (Resident #68) sample selected residents. This failed practice had the potential to affect 24 residents admitted in the last 30 days per Resident Census received from the Assistant Director of Nursing (ADON) 9/7/22 @ 3:05 PM. The findings are: 1. Resident #68 had diagnoses of Down Syndrome, Dementia, Epilepsy, Cognitive Communication Deficit and Asthma. admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/15/22 scored a 0 (0-7 severe cognitive impairment) and required extensive 2-person physical assistance for bed mobility, transfers & toilet use, and extensive 1-person physical assistance for eating. a. On 09/06/22 at 08:17 PM, Record review showed no Pre-admission Screening and Resident Review (PASSR) and found Care Plan (CP) was blank except for .at risk for exposure to and contracting COVID 19 . 2. On 09/09/22 at 09:48 AM, the Surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure razors were stored in a manner to prevent accidents or hazards for 1 (Resident #236) sampled resident. This failed practice had the potential to affect 15 residents who reside on Section 1 that were able to ambulate or wheel themselves in their wheelchair with no assistance by staff according to a list provided by the Director of Nursing on 9/9/2022. The Findings are: 1. Resident #236 had diagnosis of Alzheimer's disease with late onset and unspecified dementia with behavioral disturbance. The admission Minimum Data Set with and Assessment Reference Date (ARD) of 9/1/2022 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and required extensive assistance of 2 persons for personal hygiene. Physician's orders documented, .Routine Personal Care As needed (PRN) dated 8/21/2022 . The resident's plan of care documented, .The resident has an Activity of Daily Living (ADL) self-care performance deficit r/t [related to] Activity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure physician ordered nutritional supplements and diet were provided for 1 (Resident #75) sampled resident who was to receive a No Added Salt regular diet and 21 residents who required fortified foods with all meals. This failed practice had the potential to affect 21 residents who required fortified foods with all meals and one resident who required a No Added Salt diet as identified by a list provided by the Certified Dietary Supervisor on 9/9/22 at AM. The findings are: 1. Resident #75 had diagnoses of End Stage Renal Disease, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, and Anemia in chronic kidney disease. admission Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 08/25/22 indicated the resident received a score of 14 (13-15 cognitively intact) on the Brief Interview for Mental Status [BIMS]. a. On 9/07/22 at 9:24 AM, The Surveyor asked Resident # 75 if she had any concerns about the food. She stated, The dietician needs to follow orders better and look after her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, facility failed to ensure all components of the Antibiotic Stewardship Program were completed for all infections and prescribed antibiotics. This failed practice had the potential to affect 99 residents per facility resident Census received from Assistant Director of Nursing (ADON) on 9/7/22 @ [at] 3:05 PM. The findings are: 1. On 09/08/22 at 11:13 AM, During Infection Control & Preventionist (ICP) interview, ICP stated she has only been at facility 1 month. ICP certificate verified dated 2/20/22. Second certificate provided to surveyors by Director of Nursing (DON) 9/7/22 documented DON had ICP certificate dated 3/7/20. Surveyor asked ICP her process for checking antibiotic use and implementing the Antibiotic Stewardship Program. ICP stated, I'll run report to see that they [residents] are now on antibiotic. I will go through nurses notes and discharge (d/c) orders from hospital for a new resident on antibiotics. ICP paused. Surveyor asked, What criteria do you use to ensure the need for the antibiotic? ICP stated, (Named Program) is used to help…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure COVID-19 vaccinations or exemptions were received for all employees working in facility and failed to ensure accurate and up-to-date tracking of direct hire and contracted employee COVID-19 vaccinations to help prevent the spread of COVID-19. This failed practice had the potential to affect 99 residents per facility resident Census received from Assistant Director of Nursing (ADON) 9/7/22 @ [at] 3:05 PM. The findings are: 1. On 09/07/22 at 10:10 AM, Surveyor received partial Staff Vaccination Matrix from Consultant. Surveyor requested the remainder of staff. 2. On 09/08/22 at 10:09 AM, Surveyor received Agency Staff Vaccination matrix from Infection Control Preventionist (ICP). 3. On 09/08/22 at 12:30 PM, Surveyor received Other Staff Vaccination Matrix from ICP. 4. On 09/08/22 at 01:18 PM, Surveyor received Therapy contracted staff matrix from ICP. 5. On 09/08/22 at 01:27 PM, Consultant found Surveyor on 200 hallway and stated she has informed the ICP that all COVID declinations will be completed today, and calls…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.