Siloam Healthcare, LLC

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure that food was prepared in accordance with professional standards for food service safety by not keeping the grease trap clean of charred food particles and spillage.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Facility-wide Assessment included pertinent information to determine what resources were allocated to care and to meet the needs of the residents competently during both day-to-day operations, and emergencies in 1 of 1 facility. This deficient practice had the potential to affect all residents of the facility. The total census was 83 residents.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 1 (Resident #88) of 22 residents reviewed for MDS accuracy. Specifically, the facility failed to ensure information regarding the resident's dialysis assessment was accurately completed for Resident #88.

Inspectors wroteBased on record review and interviews, the facility failed to ensure physician order changes were immediately initiated for 1 (Resident #13) of 5 residents reviewed for anti-psychotic medications.

Inspectors wroteF689 Based on observations, record review, interviews, document review, and facility policy review, the facility failed to investigate to determine the causative factors of falls to facilitate development of effective interventions to prevent further falls and minimize the risk of fall-related injuries for 1 (Resident #35) of 3 sampled residents reviewed for accidents, which resulted in numerous abrasions and two separate hematomas to the forehead resulting from a fall for Resident #35.

Inspectors wroteBased on observation, interview and record review the facility failed to assess resident for edema and administer prescribed, as needed medication, according to physician's orders for 1 (Resident #7) of 1 sampled resident who had, as needed, diuretic therapy.

Inspectors wroteBased on record review, observation and interview, the interdisciplinary team (IDT) failed to ensure 1 (Resident #29) of 1 sampled resident was assessed and deemed safe for self-administration of updraft treatments to prevent the potential of accidental overdose and or injury.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure an order was obtained to administer oxygen therapy to 1 (Resident #94) of 1 sampled resident to minimize the potential for hypoxia or other respiratory complications.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were stored in accordance with state laws and accepted standards of pharmacy practice for 2 (Resident #94, and #39) of 2 sampled residents, to prevent the possible ingestion and or injury.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure resident's personal food and beverage items stored in the 1 of 1 refrigerator were labeled and dated; and failed to ensure hand hygiene was performed during the passing of room meal trays to prevent potential cross-contamination and minimize the potential for food borne illness for residents who stored food items and beverages in the refrigerator; and, received meal trays delivered to their rooms. This failed practice had the potential to affect 16 residents who eat meals in their rooms on the 200 Hall, and had the potential to affect all 90 residents who have access to the refrigerator on 100 Hall.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, facility failed to inform residents, resident representatives, and families of new suspected or confirmed cases of COVID-19 cases in the facility by 5pm the next day. This failed practice had the potential to affect 99 residents per facility resident Census received from the Assistant Director of Nursing (ADON) 9/7/22 @ 3:05 PM.

Inspectors wroteBased on interview and record review, the facility failed to ensure Medicaid recipient residents and/or their responsible parties were notified when their trust balance was within $200 of, or over, the maximum Medicaid recipient cash assets for 2 (Resident #12 & R#78) of 4 (Resident #12, R #33, R #45, #78) sample selected residents who were dependent on Medicaid for services and had trust funds managed by the facility. This failed practice had the potential to affect 44 residents who were dependent on Medicaid for services and had their personal trust funds managed by the facility, according to a list received from the Business Office Manager (BOM) on 9/7/22.