The Stewart Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Responsible Party, Pharmacist, Hospice Nurse and staff interviews, the facility failed to administer a probiotic ordered for 1 of 5 residents reviewed for unnecessary medications (Resident #7). The findings included: Resident #7 was admitted to the facility on [DATE] with a diagnosis of dementia. Review of physician order dated 1/14/2025 revealed, Saccharomycesboulardii 250 Milligram (MG) Oral Capsule (a probiotic). Give one capsule by mouth one time a day until 01/21/2025. Review of physician order dated 1/15/25 revealed, Doxycycline Hyclate Oral Tablet 100 MG (an antibiotic). Give one tablet by mouth two times a day for upper respiratory infection. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed she was moderately cognively impaired, her diagnoses were Alzheimer's disease, dementia, anxiety and depression, lobar pneumonia. Review of the medication administration record (MAR) dated January 2025 revealed Nurse #1 had initialed the (MAR) on 1/15/25 for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Physician, and staff interviews, the facility failed to implement an infection prevention and control program plan, failed to implement an infection surveillance plan for monitoring and tracking infections in the facility, and failed to review infection control policies annually. This practice had the potential to affect 60 of 60 residents in the facility. Findings included: The Infection Prevention and Control program policy (Revised October 2018) documented The infection prevention and control program was coordinated and overseen by the infection prevention specialist (infection preventionist), indicated Infection Control Policies should be reviewed at least annually, and Process surveillance and outcome surveillance are used as measures of the infection prevention control program (IPCP) effectiveness. The facility's infection control policy and procedure manual was provided by the administrator on entrance to the facility. The first page of the manual indicated The [NAME] Health Center…

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 staff interviews the facility failed to develop an infection prevention and control program that established an antibiotic stewardship program with written protocols on antibiotic prescribing, documentation of the indication, dosage, and duration of use of antibiotics. This was evident in 4 of 4 monthly surveillance data reviewed (December 2023, January 2024, February 2024, and March 2024.) Findings included: On 3/7/24 the Infection Preventionist (IP) provided the policy sent to her by the Regional Clinical Director. The Policy provided titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes was revised December 2016. The policy documented the antibiotic stewardship program will monitor and review all clinical infections treated with antibiotics, antibiotic utilization, identify specific situations not consistent with appropriate antibiotic use, and document all resident antibiotic regimens on the facility- approved antibiotic surveillance tracking form. The policy indicated the facility- approved antibiotic surveillance…

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 observations, record reviews, and staff interviews the facility failed to develop and implement a person-centered care plan for residents on anticoagulants (Resident # 209 and Resident #20), residents on psychotropic medications (Resident #210, #20, and #259), and a resident with a wander/elopement alarm (Resident #13) for 5 of 5 residents reviewed for development and implementation of a comprehensive care plan. Findings included: 1) Resident #209 was admitted to the facility on [DATE] with diagnoses which included chronic atrial fibrillation (irregular heart rhythm). Resident 209's care plan dated 2/15/2024 did not include goals and interventions for the use of anticoagulants. A record review revealed Resident #209 had active orders dated 2/15/2024 for apixaban (blood thinner) 5 milligrams to be administered twice a day and was to be monitored for signs and symptoms of bleeding. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #209 was moderately cognitively impaired. A review 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 observations, record review and staff interviews the facility failed to maintain a clean ice cream freezer, label and date perishable food items stored in the walk-in cooler, and label and date perishable items in the reach-in refrigerator and ensure frozen items were sealed in the walk-in freezer. These practices had the potential to affect food served to residents. Findings included: 1. The initial observation of the ice cream cooler conducted on 3/4/2024 at 9:48 am revealed pink and brown-colored substances on all four walls of the cooler. An interview was conducted with the DM on 3/7/2024 at 8:51 am. She reported the ice cream cooler was cleaned and sanitized daily. The DM stated the ice cream cooler was cleaned on 3/3/2024 and must have gotten dirty after she left. An interview was conducted with the Administrator on 3/7/2024 at 2:12 pm. The Administrator reported the ice cream cooler should be clean and sanitary. She was not aware of the pink and brown-colored substance on the walls of the ice cream cooler. 2. The initial observation of the kitchen was conducted with…

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 and staff interviews the facility failed to ensure that the resident's Medical Order for Scope of Treatment (MOST) form was signed by the resident or resident representative for 1 of 2 residents reviewed for Advanced Directives (Resident #38). The findings included: Resident # 38 was admitted to the facility on [DATE]. A review of Resident #38's paper medical record located at the nursing station revealed a MOST form dated 6/8/2023. The MOST form indicated Resident #38 was a DNR and was signed by the Nurse Practitioner (NP). The MOST form did not have the required resident or resident representative signature on the front page of the document. A review of the active physician's order dated 11/30/2023 revealed Resident #38 was a DNR. Resident #38's care plan dated 1/11/2024 revealed goals and interventions for DNR (Do Not Resuscitate) to be implemented. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was severely cognitively impaired. An interview was conducted on…

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 and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice prior to discharge from Medicare Part A skilled services for 1 of 3 residents (Resident #29) reviewed for beneficiary protection notification. The findings included: Resident #29 was admitted to the facility on [DATE]. A review of the medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was issued on 01/16/2024 to Resident #29's Responsible Party (RP) which explained Medicare Part A coverage for skilled services would end on 01/18/2024. Resident #29 was residing in the facility during the recertification survey conducted from 03/04/2024 through 03/07/2024. A review of the medical record revealed a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (ABN) was not provided to Resident #29 or their RP. An interview was conducted with the Social Worker and the Administrator on 03/06/24 at 10:05 AM.…

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 observations, record review, and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) for functional limitations in range of motion, and anticoagulant medication for 2 of 4 residents reviewed for accuracy of assessments (Residents #38 and #209). Findings included: 1. Resident #38 was admitted to the facility on [DATE] with diagnoses which included muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #38 had severe cognitive impairment, no impairment of the lower extremities, and required partial to moderate assistance from sitting to standing. An observation was conducted on 3/5/2024 at 2:43 pm. Nurse Aide (NA) #1 and NA #2 were observed using a sit-to-stand mechanical lift to transfer Resident #38 from the wheelchair to the toilet and back to his wheelchair during incontinence care. An interview was conducted on 3/5/2024 at 2:47 pm with NA #1. NA #1 reported that Resident #38 required the use of a mechanical lift during transfers due to his…

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 observations, record review, and staff interviews the facility failed to secure a mechanical lift and wheelchair during a transfer for 1 of 2 residents reviewed for Accidents (Resident #38). Findings included: Resident # 38 was admitted to the facility on [DATE] with diagnoses which included lack of coordination, muscle weakness, and essential tremors. The Minimum Data Set (MDS) dated [DATE] revealed Resident #38 required partial to minimal assistance for sit-to-stand and toileting transfer, had no impairment of upper and lower extremities, did not require the use of a mechanical lift, and was severely cognitively impaired. Resident #38's care plan dated 1/11/2024 did not include goals or interventions for using a mechanical lift. An observation was conducted on 3/5/2024 at 2:43 pm of Resident #38 as he received incontinence care. Nurse Aide (NA) #1 and NA #2 were observed as they transferred Resident #38 from his wheelchair to the toilet using a mechanical lift. As Resident #38 was moved from a sitting…

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 and staff interviews the facility failed to provide a stop date for an psychotropic medication that was prescribed as needed for 2 of 2 residents reviewed for unnecessary medications (Resident #210 and #259). Findings included: 1) Resident #210 was admitted to the facility on [DATE] with a diagnosis of delirium. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #210 was prescribed antipsychotic medications, was cognitively intact, and had not exhibited any behaviors. Resident #210 was prescribed Seroquel (antipsychotic medication) 12.5 milligrams every 12 hours as needed for behaviors on 2/15/2024 with no end date. A review of the Pharmacist's Medication Regimen Review dated 2/21/2024 was conducted. The Pharmacist had recommended discontinuing the as needed order for Seroquel by 2/29/2024. A review of Resident #210's Electronic Medication Administration Record (EMAR) revealed Seroquel 12.5 milligrams every 12 hours as needed for behaviors was active from 2/15/2024 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 observations and staff interviews, the facility failed to secure resident medications left in an unattended medication cart for 1 of 2 medication carts (Dogwood Avenue medication cart). The findings included: A continuous observation of Dogwood Avenue was conducted on 03/04/24 from 11:51 am to 11:57 am. The Dogwood Avenue medication cart was observed with the lock not engaged as evidenced by the red dot on the lock being visible. There was no staff member at the medication cart. Several staff members, residents, and visitors were observed walking past the medication cart. On 03/04/24 at 11:57 am, Nurse #2 was observed approaching the Dogwood Avenue medication cart. An observation and interview were completed with Nurse #2 upon her return to the Dogwood Avenue medication cart. She placed her key in the unengaged lock and was stopped by the surveyor. The surveyor asked Nurse #2 to open the medication cart drawer prior to turning the key, and the drawer opened. The observation revealed various prescribed and over-the-counter medications and supplies, including eye drops,…

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.