F 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed perform antibiotic stewardship for 2 of 3 residents
(R27, R39) reviewed for antibiotic stewardship in the sample of 29.
Residents Affected - Few
Findings include:
1. R27 was documented on the Infection Control log, dated 1/3/2024, for a urine infection. The organism
documented was Enterococcus aerogenes.
R27's Progress Notes, dated 1/3/2024, documented, Patient with urinary retention, suprapubic discomfort
at times, leukocytosis. UA (urinary analysis) positive. Awaiting final urine culture. Patient has a history of
pyelonephritis with pansensitive E. coli. We will start cefdinir 300 mg (milligrams) for 7 days. Adjust if
needed once culture available.
R27's Culture and Sensitivity Report, dated of 1/2/2024 at 3:14 PM, documented, Organism 1L
Enterobacter aerogenes, and documents the organism was resistant to cefdinir.
R27's Medication Administration Record (MAR) for January 2024 documented, Cefdinir (Cefzon, Omnicef)
300 milligrams (mg) oral capsule, start date 1/3/2024. R27's MAR also documents R27 received a total of
four doses, January 3-January 4,2024 for a urinary tract infection.
2. R39 was documented on the infection control log,dated 1/7/2024, for urine infection.
R39's Progress Notes, dated 1/8/2024 at 1:08 PM, Urinary tract infection associated with indwelling urethral
catheter, initial encounter (HCC). Assessment Plan: Urine cloudy, continues to have good output from
catheter. Culture positive for probable pseudomonas growth, awaiting sensitivities. Continues cefdinir for
now, will adjust medication if needed once sensitivities available.
R39's Urine Culture report, dated 1/7/2024 at 11:35 AM, documented, Final report organism 1:
Pseudomonas aeruginosa. Cefdinir (Cefzon, Omnicef). The organism was not documented as being
sensitive or resistant to cefdinir.
R39's MAR, dated January 2024, documented, Cefdinir 300 mg, 1 capsule two times a day for seven days.
Start date 1/7/2024. it continued to document that R30 received four doses from 1/7/2024 to 1/10/2024.
The facility's Antibiotic Report, dated January 2024, documented that Cefdinir as being resistant to
pseudomonas aeruginosa.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145102
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Memorial Care Center
4315 Memorial Drive
Belleville, IL 62226
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0881
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R39's MAR, dated January 2024, documented, a 1/9/2024 start date for Ciprofloxacin (Cipro 500 mg) oral
tablet every 12 hours for urinary tract infection for 7 days. R39's MAR document R39 received 7 days of the
medication.
The facility's Antibiotic Report, dated January 2024, documented for R39 that Cipro as being Sensitive for
pseudomonas.
On 1/17/2024 at 4:46 PM, V3, Infection Control Specialist, stated, Sometimes the PA (Physician Assistant)
will start the antibiotics before the Culture and Sensitivity comes back but they do a good job of following up
with them and making sure they are the correct antibiotics once the culture has been returned. When the
physician sees the C & S it shows up on their screen the exact name of the medications and if they are
resistant or have sensitivity. I myself, when I get the report there is only one or two letters for the drugs. I
have a sheet from the pharmacy documenting what drug is what.
R27's MAR, dated January 2024, also documented an order, Sulfamethoxazole-trimethoprim, (Bactrim DS
(double strength), 800 mg to 160 mg, oral tablet. Start date 1/5/2024.
The Antibiotic Stewardship Program Policy, dated of 9/22, documented, To provide guidelines to optimize
the treatment of infections while reducing the adverse events associated with antibiotic use. It is the policy
of this community to implement an Antibiotic Stewardship Program as part of the community's overall
infection prevention and control program. It promotes the appropriate use of antibiotics and is a system of
monitoring to improve resident outcomes and reduce antibiotic resistance. Antibiotics will be prescribed for
the correct indication, dose and duration to appropriately treat the resident while attempting to reduce the
development of antibiotic-residents organisms or other adverse consequences or outcomes. This program
will be reviewed on an annual basis and as needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145102
If continuation sheet
Page 2 of 2
