The Estates at Knightsbridge

Based on observation and staff interview, the facility failed to ensure dishwasher temperatures met the requirements. The facility also failed to ensure clean dishes were handled in a sanitary manner. This had the potential to affect all 32 residents in the facility.

Findings include:

1) Observation of the kitchen on 11/19/25 at 11:40 A.M. Dietary Manager (DM) #300 sent an empty dish rack through the dishwasher for cleaning. Temperatures for wash and rinse did not go higher than 150 degrees Fahrenheit. DM #300 sent approximately four additional racks through the dishwasher and wash and rinse temperatures did not go higher than 150 degrees Fahrenheit. During an interview at the same time, DM #300 stated the wash temperature should be 160 degrees Fahrenheit and rinse temperature should be 180 degrees Fahrenheit. DM #300 verified the dish machine did not reach the required temperatures.

2) Observation of the kitchen on 11/19/25 at 11:43 A.M. revealed Dietary Aid (DA) #305 loaded dirty dishes onto racks and sent the racks through the dishwasher. DA #305 was observed to wipe her nose with her bare hand as she was walking to the opposite end of the dishwasher. DA #305 then unloaded the clean dishes from the racks. DA #305 was not observed to wash her hands between loading the soiled dishes into the rack and unloading the clean dishes from the rack.

During an interview on 11/19/25 at 11:45 A.M., DA #305 verified she did not wash her hands between handling dirty dishes and handling clean dishes.

During an interview on 11/19/25 at 11:46 A.M., DM #300 verified DA #305 should have washed her hands between handling dirty dishes and handling clean dishes. DM #300 further stated there are normally two employees who run the dishwasher together, one handling the dirty dishes and the other handling the clean dishes; however, the other employee was on a break.

This violation is a recite to the annual survey completed on 02/18/25.

Based on medical record review, staff interview, facility investigation document review, and facility policy review, the facility failed to ensure all residents were safe while in the facility and failed to thoroughly investigate an incident. This affected one (Resident #42) of three residents reviewed for elopement. The census was 41.

Findings include:

Resident #42 was admitted to the facility on 03/10/23. Her diagnoses were acute respiratory failure, pleural effusion, congestive heart failure, mild cognitive impairment (03/10/23), chronic atrial fibrillation, edema, adult failure to thrive, depression, osteoporosis, anxiety disorder, scoliosis, hyperlipidemia, low back pain, spinal stenosis, and dementia. Review of her level of care assessment, dated 06/09/25, revealed she had a mild cognitive impairment with confusion.

Review of Resident #42's progress notes, dated 08/17/25, revealed an elopement incident in which Resident #42 walked out of the secured facility without supervision. She was last seen in the facility at approximately 11:30 A.M. At approximately 12:00 P.M., staff heard a door alarm activated. Staff checked both sets of doors and did not find a resident near them or in the near vicinity outside the facility; the alarms were deactivated at that time. The staff started to account for all the residents and found Resident #42 was not accounted for. A code silver was called, which indicated a missing resident. After looking for about 20 minutes, Resident #42 was found across the street in the sister building's parking lot. She was fully assessed and found to have no injuries at that time.

Interview with Registered Nurse (RN) #101, Caregiver #110, Caregiver #111, Caregiver #112, and Security Staff #120 on 09/03/25 at 10:54 A.M., 11:20 A.M., 11:30 A.M., 11:43 A.M., and 12:38 P.M. confirmed Resident #42 was found outside the facility, unsupervised, when she was assessed as being unsafe to be alone outside of the building. All confirmed Resident #42 was not to be outside the facility unsupervised; and she was already deemed an elopement risk. Caregiver #110 confirmed the last time they saw Resident #42 was at approximately 11:30 A.M.; they finally found her outside at approximately 12:20 P.M.

Interview with Facility's Director #150 on 09/03/25 at 2:15 P.M. confirmed the facility did not complete any documented interviews with staff and/or residents/witnesses.

Review of facility Elopement Drill Evaluation form, dated 08/17/25, confirmed Resident #42 left the facility unsupervised. There were no interview statements collected regarding this incident.

Review of facility Wandering and Elopement policy, dated 03/13/25, revealed the definition of wandering was the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specific course of known direction. Unsafe wandering was defined as occurring when an at risk resident, without supervision is exit seeking or attempts to leave the community/secured area but does not cross the threshold of a secured area. Elopement was defined as when a resident (who is cognitively or physically impaired) leaves the community/secured area without necessary authorization and/or necessary supervision to do so. Team members receive appropriate training on wandering and elopement management. This will occur at minimum, during orientation and annually. If a resident is determined to be at risk for wandering and elopement, educational materials will be available concerning the risk for elopement. Specific interventions are provided to the resident and family and are documented in the resident's record. All residents will be evaluated to determine their risk for elopement. The elopement risk is completed upon admission, every six months or semi-annually, upon a change in status/condition as it related to unsafe wandering or a significant change in mental status, after a wandering or elopement attempt, or as required by state regulations. The facility will develop and/or update the resident's individualized service plan (ISP) as soon as practical and review with clinical team members if the resident is determined to be at risk for elopement. The ISP will include interventions to minimize the potential for resident elopement. In the event that a wanderguard alarm is activated, team members will initiate an active search to account for anyone wearing a wanderguard bracelet. If the resident is not immediately located, the missing resident procedure will be initiated to locate resident. In the event that an exit door alarms, team members on that unit will be responsible to assure that all the residents residing on that unit are located and accounted for.

Review of facility Incident Reporting and Investigation policy, dated 05/20/22, revealed an incident was defined as an unusual or unexpected event that is not consistent with the routine operation of the community or routine care of, or services provided to, a resident; an event involving a resident or visitor with unintended, undesirable or unexpected result/outcomes; or a reportable incident. Incidents are promptly and thoroughly investigated. The person entering the incident report should ensure there is a witness statement for any team member who witnesses the incident.

This violation represents non-compliance investigated in complaint number OH00168114.

Based on observation, staff interview, and facility policy review, the facility failed to appropriately store and date food and maintain a sanitary environment in the kitchen. This had the potential to affect all 40 residents who consumed food from the kitchen. The facility identified no residents who consumed nothing by mouth. The facility census was 40.

Findings include:

1. Observation on 02/18/25 from 9:08 A.M. to 9:10 A.M. in the walk-in refrigerator revealed a large container of sour cream opened and undated and two unlabeled and undated rectangular items wrapped in tin foil.

Interview on 02/18/25 at 9:10 A.M. with Culinary Director (CD) #49 stated the facility's policy was any food item that was opened needed to be dated. CD #49 confirmed the sour cream did not have an open date and the rectangular items wrapped in foil was not labeled or dated. CD #49 discarded the sour cream and stated the rectangular items were banana bread that had just been baked.

Observation on 02/18/25 at 9:14 A.M. revealed a can of cut sweet potatoes and a can of diced pears, both with significant dents, and both were stored on the canned goods racks.

Interview on 02/18/25 at 9:14 A.M. with CD #49 stated dented cans should be pulled and returned to vendor. CD #49 confirmed the cans of diced pears and sweet potatoes were dented.

Review of the facility policy titled Food Safety in Receiving and Storage dated September 2018 revealed opened food items should be dated and dented cans are to be pulled and returned to vendor.

2. Observation on 02/18/25 at 11:40 A.M. of ceiling vent in kitchen area above aisle in front of stove revealed what appeared to be thick grey/black residue.

Observation on 02/18/25 at 11:45 A.M. of ceiling vent in area where food was plated for residents revealed what appeared to be thick grey/black residue. In the same room, there was a dark brown substance approximately one third inch wide and twelve inches long along the top ledge on the cold air vent on the wall.

Interview on 02/18/25 at 11:45 A.M. with CD #49 stated that maintenance is responsible for cleaning the vent areas. CD #49 took a paper towel and wiped the vent in the main kitchen, and confirmed the grime had transferred to paper towel, and stated he would request the vents to be cleaned.

Review of the Food Service Sanitation facility policy dated July 2024 revealed all kitchen and dining venues must be maintained at high levels of cleanliness and sanitation to ensure that all food is stored, prepared and served in a safe and sanitary environment.

Based on record review, observation, resident and staff interview and facility policy review, the facility failed to post No Smoking signage on resident doors where oxygen was in use. This affected two (Residents #31 and #36) of two residents residing in facility with physician orders for oxygen. The facility census was 40.

Findings include:

1. Review of Resident #31's medical record revealed they were admitted to the facility on 02/14/17. Diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure.

Review of Resident #31's physician orders revealed an order dated 03/01/21 for continuous oxygen at two liters.

Observation on 02/18/25 at 3:45 P.M. and at 4:14 P.M. revealed Resident #31 had no signage on their door related to oxygen usage.

Interview on 02/18/25 from 4:12 P.M. to 4:14 P.M. with Caregiver #31 confirmed Resident #31 wore oxygen. Caregiver #31 verified Resident #31 did not have signage on their doors related to oxygen usage.

2. Review of Resident #36's medical record revealed they were admitted to facility on 01/23/24. Resident #36 had diagnoses of chronic obstructive pulmonary disease (COPD), emphysema, and acute ischemic heart disease.

Review of Resident #36's physician orders revealed an order dated 01/28/25 for continuous oxygen at three liters.

Observation and interview on 02/18/25 at 3:47 P.M. revealed Resident #36 was in their room with oxygen in use. There was no sign on their door indicating that oxygen was in use or prohibiting smoking. Resident #36 was wearing oxygen in her room and said they weren't sure why there wasn't a No Smoking sign on their door.

Interview on 02/18/25 from 4:12 P.M. to 4:14 P.M. with Caregiver #31 confirmed Resident #36 wore oxygen. Caregiver #31 verified Resident #36 did not have signage on their doors related to oxygen usage.

Review of facility documentation titled Oxygen Safety: General Guidelines dated 09/01/19 revealed guidance of posting a prominent sign noting oxygen is in use to advise residents and visitors of oxygen hazards.

Review of the facility policy titled Oxygen Concentrator dated 09/01/19 revealed No Smoking signs are to be placed outside the resident's room when oxygen concentrator is delivered.