Shalom Heritage Llc-faith Nsgh

Based on record review and interview, the administrator failed to ensure an employee provided evidence of freedom from infectious tuberculosis on or before the date the individual began providing services at the facility, for one of two employees sampled who were expected to have more than eight hours per week of direct interaction with residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E3’s personnel record revealed evidence of documentation of signs, symptoms, and risk assessment TB screening. E3’s personnel record included documentation of a chest Xray, electronically signed by a medical provider on April 5, 2022, which indicated “No evidence of active pulmonary TB.” However, evidence of a negative two-step skin test, a negative blood test, or other documentation of an evaluation by a medical provider or local health authority, indicating E3 was free from infectious TB, was unavailable for review. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, document review, and interview, for one of two personnel members sampled, the administrator failed to ensure a personnel member provided current documentation of cardiopulmonary resuscitation (CPR). The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E2’s personnel record revealed a copy of documentation indicating E2 had completed CPR training specific to adults, through “American Health Care Academy.” However, the documentation did not indicate E2 performed an in-person assessment of E2’s ability to perform CPR. 2. Research conducted through https://cpraedcourse.com/, revealed the organization provided online instruction in CPR only and did not provide an in-person assessment of a person’s ability to perform CPR. 3. A review of facility staffing schedules revealed documentation indicating E2 worked numerous shifts in September, October, and November 2025. 4. In an exit interview, findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order. Findings include: 1. A review of R2’s medical record revealed a medication order, dated September 28, 2025, for “Levothyroxine Sodium 100 MCG, Oral Tablet, take ONE tablet by mouth every day before breakfast.” Further review revealed a medication administration record (MAR) for October 2025, used for documenting the administration of medications to R2. The record reflected “Levothyroxine 100 mcg” was not documented as being administered as ordered to R2 on October 25 through October 28, and on October 30 and 31, 2025. 2. In an exit interview, E1 reported the medication was administered per the physician’s orders. The findings were reviewed with E1, and no additional information was provided.