Heritage Corner

Based on observation, medical record review, review of the Incident Log, family interview, hospice interview, staff interview and review of the Resident Agreement, the facility failed to ensure sufficient staff to provide adequate supervision for residents on the secured memory care unit (MCU). This affected two (#43 and #47) of three residents reviewed for falls, with the potential to affect all seven (#41, #42, #43, #44, #45, #46, and #47) residents residing on the MCU. The facility census was 38.

Findings include:

1. Record review for Resident #43 revealed an admission date of 12/30/24 with diagnoses of multiple myeloma, cerebral atherosclerosis, and restlessness and weakness.

Review of the Initial Assessment, dated 01/03/25, revealed Resident #43 was confused and oriented only to person. Further review revealed Resident #43 required full (staff) assistance with toileting, mobility and walking, and transfers.

Review of the Fall Risk Evaluation, dated 01/24/25, revealed Resident #43 was at risk for falls.

Review of the care plan, updated 02/22/25, revealed fall risk interventions included to keep wheelchair locked and next to the bed or walker, keep call light pinned to clothing, and provide frequent monitoring.

Review of the Incident Log for April 2025 revealed Resident #43 had unwitnessed falls on 04/01/25, 04/21/25, 04/25/25, and 04/28/25. No serious injuries resulted from Resident #43's falls.

Interview on 05/21/25 at 11:43 A.M. with Hospice Aide (HA) #90 revealed a concern regarding staffing on the MCU. HA #90 stated she came to the facility once weekly to provide care to Resident #43 and there was often no staff on the MCU to provide care for the resident. HA #90 stated she once waited 25 minutes to be let off of the MCU after she completed care for Resident #43 because there were no staff around.

2. Record review for Resident #47 revealed an admission date of 04/24/23 with a diagnosis of Alzheimer's disease, dementia, hallucinations, and unsteadiness on feet.

Review of the care plan, dated 12/12/24, revealed Resident #47 was at risk for wandering. Interventions included supervision and redirection to avoid and prevent wandering episodes. Further review revealed Resident #47 was at risk for elopement with an intervention to provide supervision and redirection to avoid and prevent elopement.

Review of the Change in Condition Assessment, dated 03/03/25, revealed Resident #47 was at risk for falls, was oriented only to person, required full (staff) assistance with toileting, required monitoring and cueing when mobile or walking, and was at risk for wandering and elopement.

Review of the Incident Log dated March 2025 through 05/20/25 revealed Resident #47 was found in another resident's room or displaying wandering behavior on 03/22/25 and 04/01/25. Further review of the Incident Log revealed Resident #47 had unwitnessed falls on 03/12/25, 03/14/25, 03/17/25, 03/18/25, 03/19/25, 03/25/25, 04/19/25, 04/21/25, 05/11/25, 05/15/25, and 05/16/25. No injuries resulted from Resident #47's falls.

Interview on 05/20/25 at 7:58 A.M. with Provider #54, on the secured MCU, confirmed she was assigned to the MCU with seven residents and the hall on the other side of the lobby, with six residents. Provider #54 stated she had two residents outside of the MCU who required two-staff assistance and Provider #54 stated she would be off the unit while providing care to those residents, and any other residents on the hall she was assigned to. Provider #54 stated she would be on the MCU when she could be, but was unable to be there continuously throughout her shift. Provider #54 confirmed Resident #43 and Resident #47 fell frequently and further verified staff were not always on the unit to provide supervision and frequent monitoring.

Interview on 05/20/25 at 9:16 A.M. with Resident #47's husband revealed he wished the MCU always had staff present on the unit. Further interview with Resident #47's husband revealed Resident #47 often wandered and had been found sleeping in other residents' beds. Resident #47's husband confirmed Resident #47 had multiple unwitnessed falls while residing on the MCU.

Interview on 05/20/25 at 9:45 A.M. with the Administrator verified the MCU did not have dedicated staff to provide continuous supervision or assistance to the residents on the unit. The Administrator confirmed the Provider assigned to the MCU was also assigned to the hall across the lobby. The Administrator stated the unwritten expectation was for the Provider assigned to the MCU to remain near the front of the building to be available for residents on those halls.

Continuous observation on 05/20/25 from 11:00 A.M. until 11:13 A.M. revealed no staff entered the MCU. Provider #54 was observed entering the MCU at 11:13 A.M., after completing care for another resident not on the MCU.

Interview on 05/20/25 at approximately 2:00 P.M. with Registered Nurse (RN) #63 and Provider #54 revealed there were three residents (Resident #42, Resident #43, and Resident #45) who resided on the MCU and were dependent on staff for mobility.

Interview on 05/20/25 at approximately 3:10 P.M. with the Administrator revealed the MCU had not been independently staffed in years due to low census on the unit.

Interview on 05/20/25 at 3:41 P.M. with Provider #69 confirmed she was scheduled with one Provider and one nurse on second shift. Provider #69 stated she had multiple tasks to complete daily, including rooms to clean off the MCU, and evening snacks to pass to all residents throughout the facility. Provider #69 stated the Provider working with her that day was an agency Provider who was unfamiliar with the facility and residents and, therefore, Provider #69 had to provide oversight on her tasks. Provider #69 confirmed she did not have time to remain on the MCU continuously during her shift and stated she was in and out of the unit throughout her shift, meaning the MCU residents were left unsupervised.

Interview on 05/21/25 at 11:06 A.M. with the Administrator confirmed the facility had no policies, procedures, or specific staffing requirements for the secured MCU.

Interview on 05/21/25 at 2:24 P.M. with the Administrator confirmed (due to the lack of dedicated MCU staff) Resident #47 was not always supervised when ambulating, as indicated as a fall intervention on Resident #47's care plan.

Review of facility's undated Resident Agreement revealed the facility offered a secured unit for individuals suffering from cognitive disorders. Further review revealed the residents within the secured unit were more likely to escape and elope and could cause harm to themselves, therefore the wing was secured and not accessible to other residents.

This violation represents non-compliance investigated under Complaint Number OH00165436.

Based on review of the Resident Agreement and staff interview, the facility failed to develop and implement policies and procedures specific to the operation and care provided on the secured memory care unit (MCU). This affected all seven (#41, #42, #43, #44, #45, #46, and #47) residents residing on the MCU. The facility census was 38.

Findings include:

Review of facility's undated Resident Agreement revealed the facility offered a secured unit for individuals suffering from cognitive disorders. Further review revealed the residents within the secured unit were more likely to escape and elope and could cause harm to themselves, therefore the wing was secured and not accessible to other residents. Further review revealed no other information related to the policies, procedures, or staffing of the MCU.

Interview with the Administrator on 05/20/25 at 9:45 A.M. revealed the statement identified in the Resident Agreement was the only information specific to the operation of the MCU.

A follow-up interview with the Administrator on 05/21/25 at 11:06 A.M. confirmed there was no established criteria for making admission decisions to the secured MCU. The Administrator further confirmed no additional paperwork or policies were provided to representatives of residents who were admitted to the secure unit. Finally, the Administrator confirmed there were no policies, procedures, or staffing guidance specific to the secured MCU.

This was an incidental finding identified during the complaint survey.

Based on medical record review, review of the Incident Log, review of the fall check off list, and staff interview, the facility failed to develop and implement appropriate fall interventions. This affected two (#47 and #43) of three residents reviewed for falls. Additionally, the facility failed to complete neurological checks for residents who experienced unwitnessed falls. This affected two (#47 and #37) of three residents reviewed for falls. The facility census was 38. Findings include: 1. Record review for Resident #47 revealed an admission date of 04/24/23 with diagnoses of Alzheimer's disease, dementia, hallucinations, and unsteadiness on feet. Resident #47 resided on the secured memory care unit (MCU). Review of the care plan, dated 12/12/24, revealed Resident #47 was at risk for wandering. Interventions included supervision and redirection to avoid and prevent wandering episodes. Further review revealed Resident #47 was at risk for elopement with an intervention to provide supervision and redirection to avoid and prevent elopement. Review of the Change in Condition Assessment, dated 03/03/25, revealed Resident #47 was at risk for falls, was oriented only to person, required full (staff) assistance with toileting, required monitoring and cueing when mobile or walking, and was at risk for wandering and elopement. Review of the Incident Log for March 2025 through 05/20/25 revealed Resident #47 had unwitnessed falls on 03/12/25, 03/14/25, 03/17/25, 03/18/25, 03/19/25, 03/25/25, 04/19/25, 04/21/25, 05/11/25, 05/15/25, and 05/16/25. Review of the Incident Report dated 03/25/25 revealed Resident #47 was found sitting on the floor against the chair in another resident's room. Information provided does not indicate if the resident's wheelchair or walker was nearby. A fall intervention was developed to remind Resident #47 to use a walker or wheelchair. Review of the Incident Report dated 04/19/25 revealed Resident #47 was last observed at the dining room table in her wheelchair. Resident #47 was found in another resident's room, with her wheelchair still at the dining room table. Further review revealed Resident #47 had a bowel movement (BM), walked to her bathroom, then walked to the other resident's room. BM was noted to be trailed from Resident #47's bathroom to the other resident's room. The incident report did not indicate whether Resident #47 used a walker. A fall intervention was developed for Resident #47 to ask for assistance/call light. Review of Resident #47's neurological checks, initiated on 04/21/25 following an unwitnessed fall, revealed neurological checks were not completed at 10:40 P.M., 11:40 P.M., 12:40 A.M., and 4:40 A.M. because Resident #47 was sleeping. Review of the Incident Report dated 05/11/25 revealed Resident #47 was found in another resident's room, on the floor in the middle of the room without her walker or wheelchair. A fall intervention was developed for one-on-one activity during times of restlessness. Review of Resident #47's neurological checks, initiated on 05/11/25 following an unwitnessed fall, revealed neurological checks were not completed at 12:45 P.M. or 1:00 P.M. with listed reason of eating. Neurological checks were not completed at 1:45 P.M. or 2:15 P.M. with listed reason of with family. Neurological checks were not completed at 11:15 P.M. or on 05/12/25 at 3:15 A.M. with listed reason of sleeping. Review of Resident #47's neurological checks, initiated on 05/15/25 following an unwitnessed fall, revealed neurological checks were started at 12:00 A.M.. No neurological checks were completed at 12:15 A.M., 12:30 A.M., 12:45 A.M., 1:15 A.M., 1:45 A.M., 2:15 A.M., 2:45 A.M., 3:45 A.M., 4:45 A.M., 5:45 A.M. because Resident #47 was sleeping. Review of Resident #47's neurological checks, initiated on 05/16/25 following an unwitnessed fall, revealed neurological checks were started at 8:00 P.M.. Neurological checks were not completed at 8:30 P.M., 9:00 P.M., 9:30 P.M., 10:00 P.M., 10:30 P.M., 11:00 P.M. or on 5/17/25 at 12:00 A.M., 1:00 A.M., 2:00 A.M., or 3:00 A.M. with listed observation of sleeping. No neurological checks were completed during the 6:00 A.M. to 6:00 P.M. shift on 05/17/25 or 6:00 A.M. to 6:00 P.M. shift on 05/18/25. No neurological checks were completed on 05/21/25 during the 6:00 P.M. to 6:00 A.M. shift. Interview on 05/21/25 at 2:12 P.M. with the Administrator confirmed the MCU did not have dedicated staff, therefore, Resident #47 was not always supervised when ambulating. Further, the Administrator confirmed the intervention to encourage Resident #47 to use her walker or wheelchair after the fall on 03/25/25 was not implemented during the unwitnessed falls on 04/19/25 and 05/11/25. A follow-up interview with the Administrator on 05/21/25 at 3:55 P.M. confirmed Resident #47's neurological checks dated 04/21/25, 05/11/25, 05/15/25, and 05/16/25 were not completed per facility procedures. 2. Record review for Resident #43 revealed an admission date of 12/30/24 with diagnoses of multiple myeloma, cerebral atherosclerosis, and restlessness and weakness. Resident #43 resided on the secured MCU. Review of the Initial Assessment, dated 01/03/25, revealed Resident #43 was confused and oriented only to person, required full (staff) assistance with toileting, mobility and walking, and transfers. Review of the Fall Risk Evaluation dated 01/24/25 revealed Resident #43 was at risk for falls. Review of the care plan, updated 02/22/25, revealed fall risk interventions included to keep wheelchair locked and next to bed or walker, keep call light pinned to clothing, and provide frequent monitoring. Review of the Incident Log revealed Resident #43 had an unwitnessed fall in his room on 04/01/25. The fall intervention was to use the call light. Further review revealed Resident #43 had an unwitnessed fall in his room on 04/21/25. The fall intervention was to use a call light for assistance. On 04/25/25 and 04/28/25, Resident #43 had unwitnessed falls, with an intervention to keep the call light within reach and ask for assistance for both falls. Interview on 05/21/25 at 2:12 P.M. with the Administrator confirmed Resident #43's fall intervention for using a call light and/or asking for assistance after the falls on 04/01/25, 04/21/25, 04/25/25, and 04/28/25 was redundant and an ineffective intervention based on Resident #43's cognition. The Administrator stated she was not involved in the development of fall interventions during the time of Resident #43's falls. 3. Record review for Resident #37 revealed she was admitted on 01/31/25 with diagnoses of bipolar disorder, major depressive disorder, and fibromyalgia. Review of the Initial Assessment, dated 01/31/25 at 2:35 P.M., revealed Resident #37 was alert and oriented. Resident #37 required full (staff) assistance for mobility and transfers. Further review revealed Resident #37 was at high risk for falls. Review of the Incident Log revealed Resident #37 had unwitnessed falls on 03/15/25, 04/18/25, and 05/08/25. Review of Resident #37's neurological checks, initiated on 03/15/25 at 8:00 P.M., revealed the final neurological assessments scheduled for 03/19/25 on the 6:00 P.M. to 6:00 A.M. shift were not completed and crossed off with the word sleeping written across it. Review of Resident #37's neurological checks, initiated on 04/18/25 at 11:05 A.M. revealed neurological checks were not completed at 11:20 A.M. or 11:50 A.M.. Further review revealed neurological checks were not completed at 12:20 A.M. with reason listed as at lunch and at 5:50 P.M. with reason listed as at dinner. Further review revealed a neurological check was not completed at 6:50 A.M. on 04/19/25 with reason listed as sleeping. Further neurological assessments were discontinued on 04/20/25 during the 6:00 P.M. to 6:00 A.M. shift and not finished. Review of Resident #37's neurological checks, initiated 05/08/25 at 7:35 P.M., revealed neurological checks were not completed between the hours of 10:20 P.M. and 7:20 A.M., with observation stating sleeping. Interview with the Administrator on 05/21/25 at 3:55 P.M. confirmed Resident #37's neurological checks dated 03/15/25, 04/18/25, and 05/08/25 were not completed per facility procedures. Review of the facility document titled, Fall Incident Report Check Off ListBased on medical record review, review of the Incident Log, review of the fall check off list, and staff interview, the facility failed to develop and implement appropriate fall interventions. This affected two (#47 and #43) of three residents reviewed for falls. Additionally, the facility failed to complete neurological checks for residents who experienced unwitnessed falls. This affected two (#47 and #37) of three residents reviewed for falls. The facility census was 38.

Findings include:

1. Record review for Resident #47 revealed an admission date of 04/24/23 with diagnoses of Alzheimer's disease, dementia, hallucinations, and unsteadiness on feet. Resident #47 resided on the secured memory care unit (MCU).

Review of the care plan, dated 12/12/24, revealed Resident #47 was at risk for wandering. Interventions included supervision and redirection to avoid and prevent wandering episodes. Further review revealed Resident #47 was at risk for elopement with an intervention to provide supervision and redirection to avoid and prevent elopement.

Review of the Change in Condition Assessment, dated 03/03/25, revealed Resident #47 was at risk for falls, was oriented only to person, required full (staff) assistance with toileting, required monitoring and cueing when mobile or walking, and was at risk for wandering and elopement.

Review of the Incident Log for March 2025 through 05/20/25 revealed Resident #47 had unwitnessed falls on 03/12/25, 03/14/25, 03/17/25, 03/18/25, 03/19/25, 03/25/25, 04/19/25, 04/21/25, 05/11/25, 05/15/25, and 05/16/25.

Review of the Incident Report dated 03/25/25 revealed Resident #47 was found sitting on the floor against the chair in another resident's room. Information provided does not indicate if the resident's wheelchair or walker was nearby. A fall intervention was developed to remind Resident #47 to use a walker or wheelchair.

Review of the Incident Report dated 04/19/25 revealed Resident #47 was last observed at the dining room table in her wheelchair. Resident #47 was found in another resident's room, with her wheelchair still at the dining room table. Further review revealed Resident #47 had a bowel movement (BM), walked to her bathroom, then walked to the other resident's room. BM was noted to be trailed from Resident #47's bathroom to the other resident's room. The incident report did not indicate whether Resident #47 used a walker. A fall intervention was developed for Resident #47 to ask for assistance/call light.

Review of Resident #47's neurological checks, initiated on 04/21/25 following an unwitnessed fall, revealed neurological checks were not completed at 10:40 P.M., 11:40 P.M., 12:40 A.M., and 4:40 A.M. because Resident #47 was sleeping.

Review of the Incident Report dated 05/11/25 revealed Resident #47 was found in another resident's room, on the floor in the middle of the room without her walker or wheelchair. A fall intervention was developed for one-on-one activity during times of restlessness.

Review of Resident #47's neurological checks, initiated on 05/11/25 following an unwitnessed fall, revealed neurological checks were not completed at 12:45 P.M. or 1:00 P.M. with listed reason of eating. Neurological checks were not completed at 1:45 P.M. or 2:15 P.M. with listed reason of with family. Neurological checks were not completed at 11:15 P.M. or on 05/12/25 at 3:15 A.M. with listed reason of sleeping.

Review of Resident #47's neurological checks, initiated on 05/15/25 following an unwitnessed fall, revealed neurological checks were started at 12:00 A.M.. No neurological checks were completed at 12:15 A.M., 12:30 A.M., 12:45 A.M., 1:15 A.M., 1:45 A.M., 2:15 A.M., 2:45 A.M., 3:45 A.M., 4:45 A.M., 5:45 A.M. because Resident #47 was sleeping.

Review of Resident #47's neurological checks, initiated on 05/16/25 following an unwitnessed fall, revealed neurological checks were started at 8:00 P.M.. Neurological checks were not completed at 8:30 P.M., 9:00 P.M., 9:30 P.M., 10:00 P.M., 10:30 P.M., 11:00 P.M. or on 5/17/25 at 12:00 A.M., 1:00 A.M., 2:00 A.M., or 3:00 A.M. with listed observation of sleeping. No neurological checks were completed during the 6:00 A.M. to 6:00 P.M. shift on 05/17/25 or 6:00 A.M. to 6:00 P.M. shift on 05/18/25. No neurological checks were completed on 05/21/25 during the 6:00 P.M. to 6:00 A.M. shift.

Interview on 05/21/25 at 2:12 P.M. with the Administrator confirmed the MCU did not have dedicated staff, therefore, Resident #47 was not always supervised when ambulating. Further, the Administrator confirmed the intervention to encourage Resident #47 to use her walker or wheelchair after the fall on 03/25/25 was not implemented during the unwitnessed falls on 04/19/25 and 05/11/25.

A follow-up interview with the Administrator on 05/21/25 at 3:55 P.M. confirmed Resident #47's neurological checks dated 04/21/25, 05/11/25, 05/15/25, and 05/16/25 were not completed per facility procedures.

2. Record review for Resident #43 revealed an admission date of 12/30/24 with diagnoses of multiple myeloma, cerebral atherosclerosis, and restlessness and weakness. Resident #43 resided on the secured MCU.

Review of the Initial Assessment, dated 01/03/25, revealed Resident #43 was confused and oriented only to person, required full (staff) assistance with toileting, mobility and walking, and transfers.

Review of the Fall Risk Evaluation dated 01/24/25 revealed Resident #43 was at risk for falls.

Review of the care plan, updated 02/22/25, revealed fall risk interventions included to keep wheelchair locked and next to bed or walker, keep call light pinned to clothing, and provide frequent monitoring.

Review of the Incident Log revealed Resident #43 had an unwitnessed fall in his room on 04/01/25. The fall intervention was to use the call light. Further review revealed Resident #43 had an unwitnessed fall in his room on 04/21/25. The fall intervention was to use a call light for assistance. On 04/25/25 and 04/28/25, Resident #43 had unwitnessed falls, with an intervention to keep the call light within reach and ask for assistance for both falls.

Interview on 05/21/25 at 2:12 P.M. with the Administrator confirmed Resident #43's fall intervention for using a call light and/or asking for assistance after the falls on 04/01/25, 04/21/25, 04/25/25, and 04/28/25 was redundant and an ineffective intervention based on Resident #43's cognition. The Administrator stated she was not involved in the development of fall interventions during the time of Resident #43's falls.

3. Record review for Resident #37 revealed she was admitted on 01/31/25 with diagnoses of bipolar disorder, major depressive disorder, and fibromyalgia.

Review of the Initial Assessment, dated 01/31/25 at 2:35 P.M., revealed Resident #37 was alert and oriented. Resident #37 required full (staff) assistance for mobility and transfers. Further review revealed Resident #37 was at high risk for falls.

Review of the Incident Log revealed Resident #37 had unwitnessed falls on 03/15/25, 04/18/25, and 05/08/25.

Review of Resident #37's neurological checks, initiated on 03/15/25 at 8:00 P.M., revealed the final neurological assessments scheduled for 03/19/25 on the 6:00 P.M. to 6:00 A.M. shift were not completed and crossed off with the word sleeping written across it.

Review of Resident #37's neurological checks, initiated on 04/18/25 at 11:05 A.M. revealed neurological checks were not completed at 11:20 A.M. or 11:50 A.M.. Further review revealed neurological checks were not completed at 12:20 A.M. with reason listed as at lunch and at 5:50 P.M. with reason listed as at dinner. Further review revealed a neurological check was not completed at 6:50 A.M. on 04/19/25 with reason listed as sleeping. Further neurological assessments were discontinued on 04/20/25 during the 6:00 P.M. to 6:00 A.M. shift and not finished.

Review of Resident #37's neurological checks, initiated 05/08/25 at 7:35 P.M., revealed neurological checks were not completed between the hours of 10:20 P.M. and 7:20 A.M., with observation stating sleeping.

Interview with the Administrator on 05/21/25 at 3:55 P.M. confirmed Resident #37's neurological checks dated 03/15/25, 04/18/25, and 05/08/25 were not completed per facility procedures.

Review of the facility document titled, Fall Incident Report Check Off List

Based on observation, staff interview, Fire Inspector (FI) interview, hospice provider interview, review of the Fire Safety Inspection Report and medical record review, the facility failed to ensure there was an unobstructed emergency egress (means of exit) for residents on the secured memory care unit (MCU). This resulted in Real and Present Danger and the potential for serious harm and/or death for Resident #41, Resident #42, Resident #43, Resident #44, Resident #45, Resident #46, and Resident #47, who were identified as cognitively impaired and residing on the secured MCU, when the facility failed to ensure the exits from the MCU had an automatic or delayed emergency release function to open the doors. Additionally, the MCU did not have dedicated staff who were consistently on the unit to open the locked doors to assist the residents with evacuation. Consequently, the residents residing on the MCU had no clear evacuation route in the event of a fire or other emergency situation. This affected seven (#41, #42, #43, #44, #45, #46, and #47) of seven residents identified as residing on the secured MCU. The facility census was 38. On 05/20/25 at 3:07 P.M., the Administrator was notified Real and Present Danger began on 05/20/25 when the MCU egress doors were observed to be locked and there was no delayed emergency release function. Maintenance Director (MD) #60 confirmed the doors did not have a delayed emergency release function and did not release with the activation of the fire alarms. MD #60 further confirmed the seven residents (#41, #42, #43, #44, #45, #46, and #47) residing on the MCU were dependent on the presence of staff to unlock the doors by using either an electronic badge (EB) or a master key. The MCU did not have dedicated staff who were present on the unit 24 hours per day. The Real and Present Danger was removed on 05/23/25, when the facility implemented the following corrective actions: On 05/20/25 at approximately 3:30 P.M., the Administrator reassigned Activities Director (AD) #75 to the MCU to provide continuous staff on the unit. Beginning on 05/20/25, the Administrator or designee began education for all facility staff that staff assigned to the MCU must remain on the MCU at all times, and the staff assigned to the unit must ensure they have an EB or master key with them to be able to open the doors and assist all residents residing on the MCU with evacuation in the event of an emergency. On 05/20/25, MD #60 provided a master key, in addition to the EB provided to staff, for staff to carry with them when assigned to the MCU to allow unlocking of the doors in the event of an emergency. On 05/20/25, the Administrator scheduled staff, utilizing both facility and agency staff, to ensure the MCU has dedicated staff 24 hours per day. The Administrator will be responsible for ensuring the MCU has dedicated staff 24 hours per day until a determination is made regarding the installation of delayed emergency release doors (staffing must remain continuous if not installed) and the doors are integrated with the fire suppression system. On 05/20/25, the Administrator created an education packet for staff providing MCU care regarding fire safety procedures, including dedicated staff and the necessity to have a master key available at all times, to ensure the MCU doors can be unlocked/opened in the event of an emergency. Beginning on 05/20/25, the Administrator or designee will ensure all staff are educated on the fire safety procedures and necessity to have a master key available at all times. All staff will receive the education before the start of their next scheduled shift, but no later than 05/22/25. All agency staff will receive the education prior to the start of their first scheduled shift. Beginning on 05/20/25, staff assigned to the MCU will sign in on a sign in/sign out sheet for their scheduled shift to verify resident supervision on the unit and to confirm they have a key to unlock/open the doors of the MCU. The Administrator will be responsible for ensuring staff compliance with this procedure. On 05/20/25, MD #60 contacted Information Technology (IT) #600 for consultation on addressing the MCU door release mechanism. On 05/21/25, IT #600 was onsite to evaluate the EB system and will work directly with Fire Safety Vendor (FSV) #700 to ensure the systems are tied together to allow for an automatic release of the MCU doors in the event of a fire emergency. The Administrator is responsible for continued follow-up to ensure completion of the system update. Beginning on 05/21/25, the Administrator or designee will audit the sign in/sign out sheets four times per week for two weeks, then two times a week for two weeks, and then once per week until the MCU doors are integrated with the fire safety system to verify 24 hours staff coverage and accessible key for the MCU. On 05/22/25, the Administrator began requesting quotes for the installation of delayed emergency egress doors. The Administrator will be responsible for collecting the information and presenting it to the owners to determine the next steps. Review of the staffing schedules confirmed that beginning on 05/20/25, dedicated staff were scheduled to work on the MCU. Observations on 05/20/25 and 05/21/25 verified staff were present on the MCU and had either an EB or a master key. Beginning on 05/23/25, the Administrator or designee will conduct a fire drill on all shifts to ensure compliance with facility procedures for fire safety. Although the Real and Present Danger was removed on 05/23/25, the violation continues as the facility continues to implement its corrective actions and monitor for on-going compliance. Findings include: 1) Review of Resident #41 ' s medical record revealed an admission date of 08/16/24. Diagnoses included Alzheimer ' s disease and depressed mood. Review of the Initial Assessment, dated 09/21/24, revealed Resident #41 was not oriented and required monitoring and cueing for mobility and transferring. 2) Review of Resident #42 ' s medical record revealed an admission date of 03/02/22. Diagnoses included dementia, depression, anxiety, and senile degeneration. Review of the Annual Assessment, dated 10/25/24, revealed Resident #42 was not oriented and was disoriented to circumstance. Further review revealed Resident #42 required full assistance with mobility and transferring. Review of the care plan dated 08/27/24 revealed Resident #42 required supervision and assistance with evacuation. 3) Review of Resident #43 ' s medical record revealed an admission date of 12/30/24. Diagnoses included multiple myeloma, cerebral atherosclerosis, restlessness and weakness. Review of the Initial Assessment, dated 01/03/25, revealed Resident #43 was confused and oriented to person only and required full assistance with mobility, walking and transfers. Resident #43 required supervision/assistance to evacuate the building. 4) Review of Resident #44 ' s medical record revealed an admission date of 04/26/25. Diagnoses included Alzheimer ' s disease, malignant neoplasm of the larynx, and essential hypertension. Review of the Fall Risk Assessment, dated 04/27/25, revealed Resident #44 had cognitive issues related to Alzheimer ' s disease, was confused with forgetfulness, and ambulated independently. 5) Review of Resident #45 ' s medical record revealed an admission date of 11/03/17. Diagnoses included unspecified dementia and anxiety disorder. Review of the Updated Assessment, dated 01/20/25, revealed Resident #45 was not oriented and required full (staff) assistance with mobility and transferring. Review of the care plan, dated 09/06/24, revealed Resident #45 required supervision and assistance with evacuation. 6) Review of Resident #46 ' s medical record revealed an admission date of 12/09/23. Diagnoses included Alzheimer ' s disease and anxiety disorder. Review of the Annual Assessment, dated 12/05/24, revealed Resident #46 was not oriented but was independently mobile and able to independently transfer. Review of the care plan, dated 09/07/24, revealed Resident #46 required supervision/assistance with evacuation. 7) Review of Resident #47 ' s medical record revealed an admission date of 04/24/23. Diagnoses included Alzheimer ' s disease, dementia, hallucinations, and unsteadiness on feet. Review of the Change in Condition Assessment, dated 03/03/25, revealed Resident #47 was oriented only to person and required monitoring and cueing when mobile or walking. Review of the care plan, dated 12/12/24, revealed Resident #47 required supervision and assistance to evacuate the building. Observation on 05/20/25 at approximately 7:32 A.M., upon entrance to the facility, revealed a large, open lobby area with the nurses ' station directly in front of the facility doors. Further observation revealed the MCU was to the right of the nurses ' station and another hallway was to the left (opposite the MCU). A third hallway extended the length of the facility and led to two additional halls of resident rooms, the dining room/kitchen area, and continued to the facility ' s independent living area and administrative offices. An interview on 05/20/25 at 7:58 A.M. with Provider #54 revealed she was assigned to provide care for the seven residents on the MCU, along with six additional residents on the unsecured hall, opposite the MCU and across the lobby area. Provider #54 stated she was on the MCU when she could be, but she was unable to be there continuously to provide supervision and assistance to the residents. Observation of the MCU on 05/20/25 at 8:20 A.M. revealed a set of locked, double doors were the only exit from the unit. Each door had a window measuring approximately two feet and 2.5 inches high and five inches wide. Continued observation revealed an electronic keypad near the exit door, which required an EB to release and open the doors to exit. Interview on 05/20/25 at 9:45 A.M. with the Administrator confirmed the secured MCU did not have dedicated staff, and the Provider assigned to the MCU also had responsibility for the hall located across the lobby from the MCU. The Administrator stated the unwritten expectation was for the Provider assigned to the MCU to remain near the front of the building to be available for the residents on those halls. Continuous observations on 05/20/25 from 10:48 A.M. to approximately 11:00 A.M. of the MCU, revealed Resident #41, Resident #42, Resident #43, Resident #44, Resident #45, Resident #46, and Resident #47 were all in their rooms. No staff were present on the MCU. In addition to the secured double doors leading to the lobby, an additional single door was observed near the dining area. The single door led to a fenced courtyard. With no staff on the MCU, the surveyors were unable to exit into the lobby. An attempt was made to open the locked double doors, but no emergency delayed release function was available on the doors. Further observation of the single door also revealed no emergency delayed release function. After approximately five minutes, Provider #54 noticed the surveyors waving through the windows of the double doors and unlocked the doors, allowing the surveyors to exit. Concurrent interview with Provider #54 revealed she was providing care for residents in another area of the facility and verified there was no way to exit the MCU without staff present to unlock the doors. An interview on 05/20/25 at 11:43 A.M. with MD #60 confirmed the double doors of the MCU could not be opened without an EB or a master key. MD #60 further verified the double doors did not have a delayed emergency release function in case of a fire or other emergency situation. Additionally, MD #60 confirmed the single exit door was also locked and required a master key to open it and further added the single door led to a locked courtyard, so it was not considered a true exit from the facility. A follow-up interview on 05/20/25 at 12:25 P.M. with MD #60 verified the double locked doors on the MCU did not automatically release/unlock when the fire alarms were activated. MD #60 confirmed again the only way the doors unlocked was with the use of an EB or master key. MD #60 verified the locked gate for the secured courtyard also had no automatic release and a key was needed to exit from the area. MD #60 stated when he worked at another facility, all of the locked doors had a delayed emergency release, but this facility did not have that function. A telephone interview on 05/20/25 at 2:19 P.M. with FI #88, with the State Fire Marshal ' s Office, confirmed he completed the facility ' s State Fire Inspection on 02/10/25. FI #88 stated he did not pull fire alarms as part of his inspection. FI #88 was aware the facility had a secured MCU and stated his understanding was the double doors to the secured unit would release upon activation of the fire alarm. FI #88 revealed he did not test the doors during his inspection and stated the doors would have been tested for release during the initial local inspection when the secured unit was established years ago. Upon learning that the double doors of the MCU did not automatically release when the fire alarms were activated, FI #88 stated they should. Additionally, FI #88 stated the secured unit did not require delayed egress doors because it was always staffed. FI #88 was unaware the facility ' s MCU did not have dedicated staff 24 hours per day and stated if the secured unit was not continuously staffed, the exit doors needed to have a delayed egress. An interview on 05/20/25 at approximately 2:30 P.M. with the Administrator revealed MD #60 informed her of potential concerns related to the release of the double doors on the MCU in the event of an emergency. The Administrator revealed she had the alarm pulled to check for herself and verified the double doors of the MCU did not release upon activation of the fire alarms. The Administrator further confirmed the only way to open the double doors was with an EB or a master key. An interview on 05/20/25 at approximately 3:10 P.M. with the Administrator verified the MCU unit was not continuously staffed and had not been for a long timeBased on observation, staff interview, Fire Inspector (FI) interview, hospice provider interview, review of the Fire Safety Inspection Report and medical record review, the facility failed to ensure there was an unobstructed emergency egress (means of exit) for residents on the secured memory care unit (MCU). This resulted in Real and Present Danger and the potential for serious harm and/or death for Resident #41, Resident #42, Resident #43, Resident #44, Resident #45, Resident #46, and Resident #47, who were identified as cognitively impaired and residing on the secured MCU, when the facility failed to ensure the exits from the MCU had an automatic or delayed emergency release function to open the doors. Additionally, the MCU did not have dedicated staff who were consistently on the unit to open the locked doors to assist the residents with evacuation. Consequently, the residents residing on the MCU had no clear evacuation route in the event of a fire or other emergency situation. This affected seven (#41, #42, #43, #44, #45, #46, and #47) of seven residents identified as residing on the secured MCU. The facility census was 38.

On 05/20/25 at 3:07 P.M., the Administrator was notified Real and Present Danger began on 05/20/25 when the MCU egress doors were observed to be locked and there was no delayed emergency release function. Maintenance Director (MD) #60 confirmed the doors did not have a delayed emergency release function and did not release with the activation of the fire alarms. MD #60 further confirmed the seven residents (#41, #42, #43, #44, #45, #46, and #47) residing on the MCU were dependent on the presence of staff to unlock the doors by using either an electronic badge (EB) or a master key. The MCU did not have dedicated staff who were present on the unit 24 hours per day.

The Real and Present Danger was removed on 05/23/25, when the facility implemented the following corrective actions:

On 05/20/25 at approximately 3:30 P.M., the Administrator reassigned Activities Director (AD) #75 to the MCU to provide continuous staff on the unit.

Beginning on 05/20/25, the Administrator or designee began education for all facility staff that staff assigned to the MCU must remain on the MCU at all times, and the staff assigned to the unit must ensure they have an EB or master key with them to be able to open the doors and assist all residents residing on the MCU with evacuation in the event of an emergency.

On 05/20/25, MD #60 provided a master key, in addition to the EB provided to staff, for staff to carry with them when assigned to the MCU to allow unlocking of the doors in the event of an emergency.

On 05/20/25, the Administrator scheduled staff, utilizing both facility and agency staff, to ensure the MCU has dedicated staff 24 hours per day. The Administrator will be responsible for ensuring the MCU has dedicated staff 24 hours per day until a determination is made regarding the installation of delayed emergency release doors (staffing must remain continuous if not installed) and the doors are integrated with the fire suppression system.

On 05/20/25, the Administrator created an education packet for staff providing MCU care regarding fire safety procedures, including dedicated staff and the necessity to have a master key available at all times, to ensure the MCU doors can be unlocked/opened in the event of an emergency.

Beginning on 05/20/25, the Administrator or designee will ensure all staff are educated on the fire safety procedures and necessity to have a master key available at all times. All staff will receive the education before the start of their next scheduled shift, but no later than 05/22/25. All agency staff will receive the education prior to the start of their first scheduled shift.

Beginning on 05/20/25, staff assigned to the MCU will sign in on a sign in/sign out sheet for their scheduled shift to verify resident supervision on the unit and to confirm they have a key to unlock/open the doors of the MCU. The Administrator will be responsible for ensuring staff compliance with this procedure.

On 05/20/25, MD #60 contacted Information Technology (IT) #600 for consultation on addressing the MCU door release mechanism.

On 05/21/25, IT #600 was onsite to evaluate the EB system and will work directly with Fire Safety Vendor (FSV) #700 to ensure the systems are tied together to allow for an automatic release of the MCU doors in the event of a fire emergency. The Administrator is responsible for continued follow-up to ensure completion of the system update.

Beginning on 05/21/25, the Administrator or designee will audit the sign in/sign out sheets four times per week for two weeks, then two times a week for two weeks, and then once per week until the MCU doors are integrated with the fire safety system to verify 24 hours staff coverage and accessible key for the MCU.

On 05/22/25, the Administrator began requesting quotes for the installation of delayed emergency egress doors. The Administrator will be responsible for collecting the information and presenting it to the owners to determine the next steps.

Review of the staffing schedules confirmed that beginning on 05/20/25, dedicated staff were scheduled to work on the MCU.

Observations on 05/20/25 and 05/21/25 verified staff were present on the MCU and had either an EB or a master key.

Beginning on 05/23/25, the Administrator or designee will conduct a fire drill on all shifts to ensure compliance with facility procedures for fire safety.

Although the Real and Present Danger was removed on 05/23/25, the violation continues as the facility continues to implement its corrective actions and monitor for on-going compliance.

Findings include:

1) Review of Resident #41 ' s medical record revealed an admission date of 08/16/24. Diagnoses included Alzheimer ' s disease and depressed mood. Review of the Initial Assessment, dated 09/21/24, revealed Resident #41 was not oriented and required monitoring and cueing for mobility and transferring.

2) Review of Resident #42 ' s medical record revealed an admission date of 03/02/22. Diagnoses included dementia, depression, anxiety, and senile degeneration. Review of the Annual Assessment, dated 10/25/24, revealed Resident #42 was not oriented and was disoriented to circumstance. Further review revealed Resident #42 required full assistance with mobility and transferring. Review of the care plan dated 08/27/24 revealed Resident #42 required supervision and assistance with evacuation.

3) Review of Resident #43 ' s medical record revealed an admission date of 12/30/24. Diagnoses included multiple myeloma, cerebral atherosclerosis, restlessness and weakness. Review of the Initial Assessment, dated 01/03/25, revealed Resident #43 was confused and oriented to person only and required full assistance with mobility, walking and transfers. Resident #43 required supervision/assistance to evacuate the building.

4) Review of Resident #44 ' s medical record revealed an admission date of 04/26/25. Diagnoses included Alzheimer ' s disease, malignant neoplasm of the larynx, and essential hypertension. Review of the Fall Risk Assessment, dated 04/27/25, revealed Resident #44 had cognitive issues related to Alzheimer ' s disease, was confused with forgetfulness, and ambulated independently.

5) Review of Resident #45 ' s medical record revealed an admission date of 11/03/17. Diagnoses included unspecified dementia and anxiety disorder. Review of the Updated Assessment, dated 01/20/25, revealed Resident #45 was not oriented and required full (staff) assistance with mobility and transferring. Review of the care plan, dated 09/06/24, revealed Resident #45 required supervision and assistance with evacuation.

6) Review of Resident #46 ' s medical record revealed an admission date of 12/09/23. Diagnoses included Alzheimer ' s disease and anxiety disorder. Review of the Annual Assessment, dated 12/05/24, revealed Resident #46 was not oriented but was independently mobile and able to independently transfer. Review of the care plan, dated 09/07/24, revealed Resident #46 required supervision/assistance with evacuation.

7) Review of Resident #47 ' s medical record revealed an admission date of 04/24/23. Diagnoses included Alzheimer ' s disease, dementia, hallucinations, and unsteadiness on feet. Review of the Change in Condition Assessment, dated 03/03/25, revealed Resident #47 was oriented only to person and required monitoring and cueing when mobile or walking. Review of the care plan, dated 12/12/24, revealed Resident #47 required supervision and assistance to evacuate the building.

Observation on 05/20/25 at approximately 7:32 A.M., upon entrance to the facility, revealed a large, open lobby area with the nurses ' station directly in front of the facility doors. Further observation revealed the MCU was to the right of the nurses ' station and another hallway was to the left (opposite the MCU). A third hallway extended the length of the facility and led to two additional halls of resident rooms, the dining room/kitchen area, and continued to the facility ' s independent living area and administrative offices.

An interview on 05/20/25 at 7:58 A.M. with Provider #54 revealed she was assigned to provide care for the seven residents on the MCU, along with six additional residents on the unsecured hall, opposite the MCU and across the lobby area. Provider #54 stated she was on the MCU when she could be, but she was unable to be there continuously to provide supervision and assistance to the residents.

Observation of the MCU on 05/20/25 at 8:20 A.M. revealed a set of locked, double doors were the only exit from the unit. Each door had a window measuring approximately two feet and 2.5 inches high and five inches wide. Continued observation revealed an electronic keypad near the exit door, which required an EB to release and open the doors to exit.

Interview on 05/20/25 at 9:45 A.M. with the Administrator confirmed the secured MCU did not have dedicated staff, and the Provider assigned to the MCU also had responsibility for the hall located across the lobby from the MCU. The Administrator stated the unwritten expectation was for the Provider assigned to the MCU to remain near the front of the building to be available for the residents on those halls.

Continuous observations on 05/20/25 from 10:48 A.M. to approximately 11:00 A.M. of the MCU, revealed Resident #41, Resident #42, Resident #43, Resident #44, Resident #45, Resident #46, and Resident #47 were all in their rooms. No staff were present on the MCU. In addition to the secured double doors leading to the lobby, an additional single door was observed near the dining area. The single door led to a fenced courtyard. With no staff on the MCU, the surveyors were unable to exit into the lobby. An attempt was made to open the locked double doors, but no emergency delayed release function was available on the doors. Further observation of the single door also revealed no emergency delayed release function. After approximately five minutes, Provider #54 noticed the surveyors waving through the windows of the double doors and unlocked the doors, allowing the surveyors to exit. Concurrent interview with Provider #54 revealed she was providing care for residents in another area of the facility and verified there was no way to exit the MCU without staff present to unlock the doors.

An interview on 05/20/25 at 11:43 A.M. with MD #60 confirmed the double doors of the MCU could not be opened without an EB or a master key. MD #60 further verified the double doors did not have a delayed emergency release function in case of a fire or other emergency situation. Additionally, MD #60 confirmed the single exit door was also locked and required a master key to open it and further added the single door led to a locked courtyard, so it was not considered a true exit from the facility.

A follow-up interview on 05/20/25 at 12:25 P.M. with MD #60 verified the double locked doors on the MCU did not automatically release/unlock when the fire alarms were activated. MD #60 confirmed again the only way the doors unlocked was with the use of an EB or master key. MD #60 verified the locked gate for the secured courtyard also had no automatic release and a key was needed to exit from the area. MD #60 stated when he worked at another facility, all of the locked doors had a delayed emergency release, but this facility did not have that function.

A telephone interview on 05/20/25 at 2:19 P.M. with FI #88, with the State Fire Marshal ' s Office, confirmed he completed the facility ' s State Fire Inspection on 02/10/25. FI #88 stated he did not pull fire alarms as part of his inspection. FI #88 was aware the facility had a secured MCU and stated his understanding was the double doors to the secured unit would release upon activation of the fire alarm. FI #88 revealed he did not test the doors during his inspection and stated the doors would have been tested for release during the initial local inspection when the secured unit was established years ago. Upon learning that the double doors of the MCU did not automatically release when the fire alarms were activated, FI #88 stated they should. Additionally, FI #88 stated the secured unit did not require delayed egress doors because it was always staffed. FI #88 was unaware the facility ' s MCU did not have dedicated staff 24 hours per day and stated if the secured unit was not continuously staffed, the exit doors needed to have a delayed egress.

An interview on 05/20/25 at approximately 2:30 P.M. with the Administrator revealed MD #60 informed her of potential concerns related to the release of the double doors on the MCU in the event of an emergency. The Administrator revealed she had the alarm pulled to check for herself and verified the double doors of the MCU did not release upon activation of the fire alarms. The Administrator further confirmed the only way to open the double doors was with an EB or a master key.

An interview on 05/20/25 at approximately 3:10 P.M. with the Administrator verified the MCU unit was not continuously staffed and had not been for a long time

Based on review of personnel files and staff interview, the facility failed to ensure unlicensed staff members completed training under the direction of a licensed nurse prior to providing resident care without supervision. This had the potential to affect all 34 residents in the facility.

Findings include:

Review of the personnel file for Provider #101 revealed a hire date of 11/29/24. Review of the Checklist for Providers, dated 12/05/24, revealed Provider #101 received skills training by Provider #102. The Checklist was signed by the Director of Nursing (DON).

Interview on 12/26/24 at 3:30 P.M. with the Administrator and the Director of Nursing (DON) verified Provider #101's skills training was not taught or completed by a licensed nurse. Further, the Administrator and the DON confirmed Provider #102 was not a licensed nurse.

This violation is a recite to the Survey completed 11/19/24.

Based on review of personnel files and staff interview, the facility failed to ensure unlicensed staff members completed training or continuing education taught by a registered nurse of licensed practical nurse under the direction of a registered nurse prior to providing resident care without supervision. This had the potential to affect all 36 residents in the facility. The census was 36.

Findings include:

1. Review of the personnel file for Provider #104 revealed a hire date of 09/06/24. Review of the checklist for providers, dated 09/07/24, revealed Provider #104 received skills training check-off by Provider #106.

2. Review of the personnel file for Provider #105 revealed a hire date of 03/07/24. Review of the checklist for providers, dated 03/07/24, revealed Provider #105 received skills training check-off by Provider #106.

Interview on 11/19/24 at approximately 4:30 P.M. with Human Resources Manager (HRM) #102 confirmed Provider #106 was not a nurse and was the staff member who performed the skills training check-off for Provider #104 and Provider #105.

Based on observation, medical record review, review of a menu, staff interview, and review of the menu, the facility failed to ensure residents on a therapeutic diet received all components of the meal. This affected four (#13, #29, #38, and #45) of four residents reviewed for therapeutic diets. The facility census was 36.

Findings include:

1. Review of the medical record for Resident #13 revealed an admission date of 02/18/23 with diagnoses hypothyroidism and hypertension.

Review of a current physician order dated 07/05/24 revealed Resident #13 received a minced and moist diet.

2. Review of the medical record for Resident #29 revealed an admission date of 05/18/17 with diagnoses of Alzheimer's disease and dysphagia.

Review of a current physician order dated 08/26/24 revealed Resident #38 received a minced and moist diet.

3. Review of the medical record for Resident #38 revealed an admission date of 02/10/17 with diagnoses of Alzheimer's disease and hyperlipidemia.

Review of a current physician order dated 10/11/24 revealed Resident #38 received a pureed diet.

4. Review of the medical record for Resident #45 revealed an admission date of 12/04/23 with diagnoses of Alzheimer's disease and abnormal weight loss.

Review of a current physician order dated 04/09/24 revealed Resident #45 received a minced and moist diet.

Review of the menu for the noon meal on 11/19/24 revealed residents were to receive a turkey delicatessen (deli) sandwich.

Observation on 11/19/24 at 11:55 A.M. revealed Cook #100 serving the noon meal. Cook #100 provided two slices of bread, four ounces of turkey, and one ounce of cheese on each sandwich provided to residents on a regular diet. Continued observation revealed Cook #100 used a previously prepared ham salad to serve to residents on a texture modified diet. Cook #100 provided the ham salad to Resident #13, Resident #29, Resident #38 and Resident #45. Concurrent interview with Cook #100 during the observation confirmed she provided the same texture to residents on a minced and moist diet and Resident #38 on a pureed diet. Cook #100 confirmed she prepared the ham salad the previous day and it did not include bread or cheese. Cook #100 confirmed she did not provide an alternative menu item on the plate to substitute for the omitted bread and cheese for the residents on a texture modified diet.

Based on observation and staff interview, the facility failed to serve food in a manner to prevent contamination. This had the potential to affected all 36 residents residing in the facility. The facility census was 36.

Findings include:

Observation during meal preparation on 11/19/24 at 11:30 A.M. revealed Cook #100 changed her disposable gloves without washing her hands, touched the outside of a bag of shredded cheese, opened the bag, and reached inside with her hand.

Interview on 11/19/24 at 11:31 A.M. with Cook #100 confirmed she touched the outside of the shredded cheese bag and did not change gloves before reaching into the bag and touching the cheese.

Interview on 11/19/24 at 5:23 P.M. with the Administrator confirmed only clean gloves should be used when touching food.

Based on observation and staff interview, the facility failed to ensure food was transported in a manner to prevent contamination. This had the potential to affect all 36 residents in the facility. The census was 36.

Findings include:

Observation of lunch preparation on 11/19/24 at 11:22 A.M. revealed Cook #100 transported a large pot of soup out of the kitchen, down a hallway, and into the dining area serving room without covering the pan of soup.

Interview with Cook #100 on 11/19/24 at 11:25 A.M. confirmed soup was transported from the kitchen area to the dining area without a cover.