Every finding on record at Special Tree Neurocare Center

This citation has two deficient practices. Deficient Practice #1. Based on interview and record review, the facility failed to ensure adequate temperature monitoring and documentation of the facility's hot water tank and water storage tank, resulting in the potential for inadequate water temperatures to go undetected that could cause the growth and spread of waterborne pathogens. Findings: On 8/6/25 beginning at 12:38 PM, interviews and record reviews were conducted with the Maintenance Director and the Nursing Home Administrator (NHA) regarding the building’s water system. The NHA confirmed that water management was addressed within the Water Management Plan (WMP), rather than through a separate policy. The facility’s WMP was reviewed with the Maintenance Director and NHA and revealed in part the following: - A written record is required to document monitoring, compliance with control limits, performance of corrective actions, and WMP validation. Maintain water testing documentation to be retrievable for at least three years. Maintain the following minimum documentation for this WMP. Logs required for normal operation and system maintenance shall continue to be maintained: Temperature (heaters, return, distal outlets, mixing valve logs). The facility shall manage the water system to maintain operation within these limits. If a limit is exceeded a corrective action shall be implemented to control the growth or spread of Legionella in the water system. - Control Measure: Hot Water Generation Temperature Control Limit: >140ºF (Fahrenheit) Monitoring Method: Record the temperature at each hot water heater after a 60-second flush. Frequency: Weekly Responsible: Facilities - Control Measure: Hot Water Return Temperature Control Limit: >120ºF Monitoring Method: Check pumps for operation and document temperature from gauge. Frequency: Weekly Responsible: Facilities During the review of the WMP, the Maintenance Director identified the “hot water generation temperature” as the hot water tank, and the “hot water return temperature” as the storage tank that stores water after it has been mixed with cooler water. The Maintenance Director stated, “We have not been recording those temperatures.” The Maintenance Director said water temperatures should be obtained and documented to make sure the mixer does not fail to prevent scalding and to make sure our population does not get sick from Legionnaires Disease. The NHA stated, “We want to make sure the water temperatures are appropriate and comfortable for the residents. We monitor water temperatures to minimize the risk of Legionnaires Disease.” On 8/7/25 at 8:50 AM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked. Deficient Practice #2 Based on observation, interview and record review, the facility failed to ensure one resident (R4) of one resident reviewed for Enhanced Barrier Precautions (EBP) was administered care in a manner to prevent transmission of microorganisms. This failure occurred when staff did not wear a gown as required for high contact resident care activities involving a resident with a peripherally inserted central catheter (PICC) line and an open wound. This deficient practice had the potential to place R4 and other residents at risk for the transmission of infectious agents Findings include: Findings include: On 8/5/25 at 2:15 PM, the State Agency (SA) observed Registered Nurse (RN) “H” administer intravenous (IV) antibiotics to R4. (RN) “H” did not wear a gown while providing care, despite R4 having a PICC line. On 8/6/25 at 9:26 AM, RN “J” observed by the SA to perform wound and hygiene care for R4. (RN) “J” did not wear a gown while providing care, despite R4 having an open wound. On 8/6/25 at 2:05 PM, RN “J” was observed to administer (IV) antibiotics to R4 without wearing a gown, despite the resident having a PICC line. On 8/6/25 at 9:55 AM, RN “J” was interviewed and said they believed they were only required to wear a gown if the resident had tested positive for a multidrug-resistant organisms (MDROs). On 8/6/25 at 10:03 AM, he Assistant Director of Nursing (ADON) was interviewed and acknowledged R4 had a PICC line and an open wound. ADON said R4 was not on EBP because R4 had not tested positive for an infectious disease. On 8/6/25 at 3:00 PM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were interviewed. They both acknowledged R4 had a PICC line and an open wound. The DON said they did not believe R4 had to be on EBP because R4 had not tested positive for infectious disease and R4 was not colonized. The NHA was present and did not provide any additional information. Record review revealed R4 was admitted on [DATE] with diagnosis that included paraplegia, pressure ulcer sacral region stage IV, and osteomyelitis sacral. Review of Minimum Data Set (MDS) dated [DATE] indicated R4 Brief Interview for Mental Status was a 15 out of 15 cognitively intact. Review of document titled “Enhanced Barrier Precautions,” undated, documented the purpose is, “ .to reduce the risk of transmission of multidrug-resistant organisms (MDROs) . the use of gloves and gown for high contact resident care activities . High contact activities: Activities where healthcare personnel have contact with resident skin, medical devices, or bodily fluids . The document included the following procedures: dressings, providing hygiene care, wound care, device care including central lines.

Based on observation, interview, and record review, the facility failed to: 1. Ensure cleaned mixing bowls and ladles were properly stored; 2. Properly clean surfaces in the kitchen; 3. Ensure food items past the use-by-date were not stored with active food stock; 4. Ensure food was properly stored in the freezer; and 5. Properly label food stored in a resident refrigerator. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food-borne illness. Findings include: The initial tour of the kitchen on Tuesday, 8/5/25 at 9:10 AM was conducted with Hospitality Service Manager (HSM) A and Registered Dietitian (RD) F. The following was observed stored in the clean pot and pan area:1. Four metal mixing bowls, identified by HSM A as one large size bowl and three medium size bowls, were not inverted and not covered.2. Ten ladles of varying sizes were hanging from a rack, bowl side up.3. Three third-size pans were observed wet and nestled together. The top surface of the commercial oven appeared soiled. When HSM A wiped the top of the oven with a damp paper towel, she said, That's not good. It's dirty. The two stove drip trays were observed to be full of debris. Dietary Aide/Cook G said the stove drip trays are cleaned twice a week. The following was observed stored inside of the walk-in cooler:1. A four-quart size container 1/4 full of fruit cocktail labeled with a use by date of 8/4/25.2. RD F stated that the following items should have been used or discarded within five days of the date on the package: three pounds of grated parmesan cheese dated 7/27/25, eight slices of Swiss cheese dated 7/28/25, and seven slices of American cheese dated 7/30/25. Inside of the walk-in freezer, a plastic bag of hot dogs was observed unsealed and opened to the freezer air. On 8/5/2025 at 12:25 PM, an opened bag of sweet treats, not identified with a resident's name, was observed stored in the resident refrigerator in the North dining room pantry. RD F said this has to be discarded because it was not labeled with a resident's name. On 8/6/2025 at 3:04 PM, the Nursing Home Administrator (NHA) said staff have been trained on their jobs and protocols, and it is expected that they perform their job. On 8/7/25 at 8:50 AM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked. A review of the facility document titled, Cleaning Check List and Tasks, undated but provided during the survey, revealed the following: On Monday the Day [NAME] was responsible to clean ovens, stovetop, backsplash and change foil in drip pans. A review of the facility document titled, Food Receiving and Storage, undated but provided during the survey, revealed in part the following for Refrigerated/Frozen Storage: - The use-by date is the last date that food can be consumed. Staff will monitor for foods that have reached their designated use-by date and discard them at the end of that date.- Food stored frozen should be stored no longer than 3 months for quality. Food will be sealed/wrapped tightly to prevent contamination and shelved to allow for adequate circulation. A review of the facility document titled, Manual Dish and Pot Washing, undated but provided during the survey, revealed that all dishes, pots and pans are to air dry before being stored. A review of the 2013 FDA Food Code documented the following:Section 4-903.11. Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.