The Stewart Health Center

In the surveyor’s words

From the most serious findings on record at The Stewart Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 23, 2025

  Based on observations, pictures captured of video footage, record review, and staff, family member, resident, and Medical Director interviews, the facility failed to ensure the necessary supervision was provided to prevent a cognitively impaired resident who was care planned as having a history of attempting to leave the facility, had impaired safety awareness, and hearing loss and aphasia (a language disorder that affects a person's ability to communicate) from exiting the building without staff knowledge. On Saturday 09/06/25, Resident #1 entered a conference room area where the inside entrance doors had been propped open by the Dietary Manger. The Dietary Manger then went to the kitchen and the left the conference room area unattended. […]

• Actual harm, isolatedF583Mar 7, 2024

  Based on observations, record review, family and staff interviews the facility failed to maintain privacy during care and failed to obtain written consent for the use of cameras in residents' rooms for 2 of 2 samples residents reviewed for privacy (Resident #13 and #38). A reasonable person would expect privacy when care was being provided and not have a monitor screen showing them with private areas exposed and would feel humiliated and dehumanized. Findings included: 1. Resident #13 was admitted to the facility on [DATE]. The admission MDS dated [DATE] revealed Resident #13 was moderately cognitively impaired and had not exhibited any behaviors. […]

• No harm, potential for more than minimal, widespreadF880Mar 7, 2024

  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… […]

• No harm, potential for more than minimal, widespreadF881Mar 7, 2024

  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. […]

• No harm, potential for more than minimal, patternF656Mar 7, 2024

  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. […]