Shiloh Nursing And Rehab, LLC

Based on observation, interview, and facility policy review, the facility failed to ensure food was thawed properly and in sanitary conditions, specifically thawing fish in a dirty sink at room temperature with no water. This failed practice had the potential to affect 4 of 4 residents who received the alternate meal choice from the kitchen. The findings are: On 02/24/2025 at 11:03 am, during the initial tour of the kitchen, a zipper sealed bag of frozen fish was observed in a sink with no water. The sink also contained a whisk and a knife with a yellow liquid substance covering them. On 02/24/2025 at 11:04 am, the Dietary Manager (DM) was asked what was in the zipper sealed bag. The DM said it was frozen fish. The DM stated that the fish was for the alternate meal choice. On 02/26/2025 at 9:06 am, the DM was asked to explain how frozen meats, fish, and poultry should be thawed. The DM confirmed that the proper way is to place the frozen food in a pan and run cold water over it. The DM was asked what could happen if frozen food was served to residents that had been thawed…

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 observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to maintain infection control prevention for 4 (Residents #24, #59, #62, and #67) of 5 residents reviewed for infection control. The findings include: A review of a facility policy titled, Medication, Insulin Injection, revised 11/22/2016, indicated, equipment and supplies needed included clean gloves which would be put on prior to withdrawal of insulin from the vial. Gloves were to be removed after administration and disposal of needle and syringe in the sharp's container. A review of a Centers for Disease Control (CDC) undated table titled, Summary of Personal Protective Equipment (PPE) Use and Room Restriction When Caring for Residents in Nursing Homes, provided by the Administrator on 02/26/2025, as the facility's guide for PPE application indicated, standard precautions applied to all residents and PPE should be utilized for situations with any potential for exposure to blood, body fluids, mucous membranes, non-intact skin, and…

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 observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to properly label and discard a medication per the manufacture's guidelines for 1 medication cart of 3 carts reviewed for medication labeling and storage. The findings include: A review of a facility policy titled, Medication Storage in the Facility, revised in January 2018 indicated, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. When the original seal of a manufacture's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The…

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 dietary staff washed their hands before serving food in the kitchen to prevent potential for cross contamination. This failed practice had the potential to affect 72 residents who received a tray from the kitchen. The findings are: 1. On 1/4/24 at 12:33 pm, observed Dietary Employees (DE) #2 and #3 standing near the food line go directly to the food line and begin serving food to the residents without washing their hands before serving food. 2. On 1/4/24 at 3:29 pm, during an interview the Surveyor asked the Dietary Manager (DM) what should an employee do before they start to serve food? The DM said wash their hands. The Surveyor asked what could happen from staff not washing their hands. The DM said if they had germs or an infection, they could pass it through the food to the residents. 3. On 1/5/24 at 8:04 am, during an interview the Surveyor asked DE #2 what should an employee do before serving food on the line? DE #2 said wash my hands. The Surveyor asked what could happen if you don't wash your hands? DE #2 said…

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 investigate in a timely manner a possible injury to 1 (Resident #42) of 1 sampled resident, who reported a possible knee injury to the nurse due to an improper transfer performed by a staff member. The findings are: 1. Resident #42 had a diagnosis of rheumatoid arthritis, reduced mobility, and muscle wasting atrophy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/07/23 documented the resident received a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and required two plus persons assistance for bed mobility and transfer. a. On 01/02/24 at 2:42 PM, Resident #42 informed the Surveyor that a few days ago when the staff was changing her, when they got ready to roll her back over, they let her leg just fall over instead of rolling her back over and she heard her right knee pop. Resident #42, then pulled back the covers for the Surveyor to observe her knee. It was swollen and much larger than her left knee and had some discolored…

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 Resident #42 had a physician's order for medication that was being administered by nurses. This had the ability to affect 16 residents who resided on 600 Hall and receive medications. The findings are: 1. On 1/2/24 at 2:42 pm, Resident #42 said that the nurses were applying (Name Brand) Pain Relieving Gel to her right knee when she asked them to. 2. On 1/3/24 at 2:48 pm, during record review it was noted Resident #42 did not have a Physician's Order for the (Name Brand) Pain Relieving Gel applied by Licensed Practical Nurse (LPN) #3. 3. On 1/4/24 at 3:54 pm, during an interview the Surveyor asked LPN #1, what should a nurse do before administering a medication? LPN #1 said look at the Medication Administration Record (MAR), and order. The Surveyor asked what should a nurse do if a resident asks for a medication that they do not have an order for? LPN #1 said call the provider. 4. On 1/4/24 at 4:02 pm, during an interview the Surveyor asked the Director of Nursing (DON) what should a nurse do before…

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 the residents was free of potential accident and hazards, as evidenced by failure to ensure that all the clips were in place on the mechanical lift when lifting 1 (Resident #63) of 1 sampled resident. This failed practice had the potential to affect 5 (Residents #24, #42, #63, #71 and #72) sampled residents who resided on the 600 Hall and were dependent on a mechanical lift for transfers. The findings are: 1. On 1/4/24 at 10:14 am observed, Certified Nursing Assistants (CNA) #2 and #5 use a mechanical lift to transfer Resident #63 from the geri-chair to the bed. The mechanical lift was missing a clip in the middle on the left side. 2. On 1/4/24 at 10:34 am, during an interview the Surveyor asked the Lead Certified Nursing Assistant (CNA) #1 if she could look at the lift and tell the Surveyor what it was missing. CNA #1 said it is missing a clip on the left side. The Surveyor asked should this lift be used when it has a missing clip. CNA #1 said no ma'am, it shouldn't. The Surveyor asked what could…

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 infection control practices were maintained during the administration of medications to decrease the risk of contamination for 1 (Resident #58) of 1 sampled resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube; staff performed hand hygiene while delivering trays to residents during the lunch meal service on the 600 Hall, and failed to ensure staff performed hand hygiene in between feeding residents who required assistance with meals during the lunch meal service. The findings are: 1. Resident #58 had diagnoses of gastro-esophageal reflux disease (GERD) with esophagitis, without bleeding, dysphagia following cerebral infarction and gastrostomy status. a. the Resident #58's Physicians Order Summary documented all oral medications to be given through the resident's PEG tube. b. A Care Plan revised 11/28/23 documented Resident #58 required tube feeding related to a swallowing problem. c. On 01/04/24 at 9:07 AM, Licensed Practical Nurse (LPN) #2 was administering Resident #58's medications through…

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 gastric contents were aspirated prior to administering medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube to decrease the potential for complications and enteral feeding bags were labeled with the date, time, and initials for 1 (Resident #58) of 1 sampled resident with a PEG tube as documented on a list provided by the Administrator on 01/04/24 at 3:52 PM. The findings are: 1. Resident #58 had diagnoses of gastro-esophageal reflux disease (GERD) with esophagitis, without bleeding, dysphagia following cerebral infarction and gastrostomy status. a. Resident #58's Physicians Order Summary, active 01/03/24, documented the Resident #58's diet was nothing by mouth (NPO). Check placement of peg tube prior to meds medications and feedings every shift. Order date 12/26/23. b. A Care Plan revised on 11/28/23 documented the Resident required tube feeding related to a swallowing problem. c. On 01/02/24 at 11:43 AM, the Resident was resting quietly in bed with a nutritional supplement infusing at…

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 cautionary signage was placed outside the room of a resident who had oxygen (O2) in use for 1 (Resident #2) of 3 (Residents #2, #4 and #127) sampled residents who had physician orders for oxygen as documented on a list provided by the Administrator on 01/04/24 at 3:52 PM. The findings are: 1. Resident #2 had diagnoses of solitary pulmonary nodule, hypoxemia, and acute respiratory failure unspecified whether with hypoxia or hypercapnia. a. The Physicians Order Summary documented, .O2 at 1L [liter] -10L L/M [liters per minute] via [by way of] Titrate O2 To Keep Sats [saturations] 90% [percent] or Greater every shift and as needed for keep 02 sat > [greater than] 90 . start date 10/12/23 . b. A Care Plan completed 10/12/23 documented, .The resident has oxygen therapy r/t [related to] SOB [shortness of breath] .OXYGEN SETTINGS: O2 @ 1L-10L/M . c. On 01/02/24 at 12:08 PM, Resident #2 was lying in bed, awake. There was an O2 concentrator on the floor that was off at this time. There was no cautionary signage…

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 dietary staff washed their hands and changed gloves before handling food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 69 residents who received meals from the Kitchen (Total Census: 69), according to the list provided by the Dietary Supervisor on 9/07/22 at 1:18 PM The findings are: 1. The following observations were made during noon and supper meal preparations: a. On 9/06/22 at 12:23 PM Dietary Employee #1 picked up the water hose with her bare hand, used it to spray off leftover food items from the dishes contaminating her hands, placed dishes in the dirty racks and pushed them into the dish washing machine to wash and after the dishes stopped washing. Dietary Employee #1, moved to the clean side in dishwasher area and without washing her hands picked up a clean blade and attached it to the base of the blender to be used to puree food items to be served to the residents for the supper…

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 4 residents who received pureed diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 9/7/22. The findings are: 1. On 9/6/22, the menu for the lunch meal documented residents who received pureed diets were to receive #8 scoop (½ cup) of pureed taco meat, pureed refried beans, pureed Mexican rice, and tortilla bread. On 9/6/22 at 12:39 PM, the following observations were made during the lunch meal: a. Dietary Employee #1 used a #16 scoop (blue scoop) which is equivalent 1/4 cup (4 ounces) to serve a single portion of pureed refried beans, pureed taco meat and pureed plain rice to residents who required pureed diets, instead of #8 scoop as specified on the menu. b. There was no Mexican rice served to the residents on pureed diets. Residents on pureed diets were served pureed plain rice,…

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 3 of 3 meals observed. This failed practice had the potential to affect 4 residents who received pureed diets, as documented on the Diet List provided by the Food Service Supervisor on 9/07/22. The findings are: 1. On 9/06/22 at 12:06 PM, Dietary Employee #1 used a 6 0z spoon to place 3 servings of plain rice into a blender, added milk and pureed. On 09/06/22 at 12:07 PM, She poured the pureed rice into a pan, covered the pan with foil and placed it in the oven. The consistency of the pureed rice was lumpy, not smooth. Pieces of rice remained in the mixture. 2. On 9/06/22 at 12:34 PM, The following items were on the steam table: a. Pureed refried beans were on the steam table. The consistency of the pureed refried beans were runny. b. A pan of pureed taco meat. The consistency of the pureed meat was gritty, not smooth. c. A pan of pureed bread was on the…

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 record review and interview the facility failed to ensure a comprehensive plan of care was developed for a resident who had a colostomy, to assure that the resident's individual needs were met and maintained for 1 (Resident #36) of 1 (Resident #36) who had a colostomy. The findings are: 1.Resident #36 had diagnoses of Cerebral Infarction, Gastrostomy, Hereditary Deficiency of other clotting factors, Aphasia, and Diverticulosis of Intestine. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 07/10/22 documented the resident scored 3 (severely impaired) on the Staff Assessment for Mental Status (SAMS) and required extensive assist of two persons for bed mobility, dressing, extensive assist of one for toileting, personal hygiene, limited assist of one person for eating, and totally dependent for bathing. a. On 09/07/22 at 11:59 AM, current Physician's Orders dated 08/01/22 documented, .CHANGE OSTOMY APPLIANCE/BAG WEEKLY ON WEDNESDAY every day shift every Wed . b. On 09/07/22, a review of R#36's Care Plan was completed, and colostomy care was not…

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.