Redbanks

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined that the facility failed to store food in accordance with professional standards for food service safety and quality. Opened foods were not dated. Expired foods and/or foods which were past their use by date were available for use and service to residents. This failure had the potential to affect 129 of 131 residents who consume food from the facility's kitchen and/or unit refrigerators.

Inspectors wroteAMENDED Based on observation, interview, record review, and facility policy review, the facility failed to ensure drugs and/or biologicals used in the facility were current for use and/or stored and labeled in accordance with currently accepted professional principles, including the expiration date when applicable. Medications and nutritional supplements were opened but not labeled with a date as to calculate the discard date. Medications were found loose, without identification as to whom they belonged and/or what they were. This failure affected three of three medication rooms observed (out of a total of five rooms) and two of five medication carts observed (out of a total of nine carts.)

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for four (Resident (R)109, R93, R37, and R41) of five sampled residents reviewed for infection control. Facility staff failed to indicate, via signage, the need for precautions, as well as provide and/or ensure the use of Personal Protective Equipment (PPE) and hand hygiene by staff and visitors for R109, who was on contact isolation precautions. Action to protect others from the risk of infection was not taken when R109 was out of her room for non-essential purposes. In addition, staff failed to follow manufacturer's instructions after cleaning/disinfecting a used glucometer used on R41. [...]

Inspectors wroteBased on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflects the resident's status for two (2) of thirty-four (34) sampled residents (Resident #10 and Resident #141). Resident #10's Quarterly Minimum Data Set (MDS) Assessment, dated 12/11/19, Section I Active Diagnosis, was coded as no infections during the seven (7) day look back period; however, review of the Physician's Orders, dated December 2019, revealed the resident was receiving an antibiotic medication for a Urinary Tract Infection. Resident #141's Quarterly MDS Assessment, dated 11/25/19, Section J Health Conditions, was coded as no falls since prior assessment; [...]

Inspectors wroteBased on observation, interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for three (3) of thirty-four (34) sampled residents (Resident #87, Resident #109, and Resident #141). Resident #87 was diagnosed and treated for a Urinary Tract Infection (UTI) in March 2020; however, the CCP was not revised related to the acute infection. Resident #109 was diagnosed and treated for Pneumonia in March 2020; however, the CCP was not revised related to the acute infection. Resident #141 had a fall event on 11/05/19; [...]

Inspectors wroteBased on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure position change alarms used as a fall prevention strategy were monitored to ensure efficacy and to ensure the alarms were the least restrictive device prior to implementation and on an on-going basis for three (3) of thirty-four (34) sampled Residents (Resident #10, Resident #96, and Resident #148). Although Resident #10 was Care Planned for the Sensor Alarm to bed and wheelchair on 01/29/19, there was no documented evidence of an Assessment for the Sensor Alarms until 03/16/19, over two (2) weeks later, in order to ensure the Alarms were effective and to ensure the Alarms were the least restrictive device to use as a fall prevention strategy. [...]

Inspectors wroteBased on interview, record review and review of the Resident Assessment Instrument (RAI) manual, it was determined the facility failed to ensure a Minimum Data Set (MDS) Re-entry was completed for one (1) of forty-six (46) sampled residents (Resident #78). Resident #78 was transferred to the hospital on [DATE] with return anticipated and returned on 11/08/18; however, a Reentry MDS was not initiated and/or completed upon the resident's return to the facility.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure it developed or implemented a comprehensive person-centered care plan for three (3) of forty-six (46) sampled residents (Resident #12, #142, and #166). Observation on 01/04/19 revealed tracheostomy care was not provided per sterile technique according to Resident #12's Comprehensive Care Plan. Observations on 01/02/19-01/04/19 revealed staff failed to ensure foot protectors were on and a pillow or blanket was in place between the resident's knees according to Resident #142's care plan. In addition, Resident #166 returned to the facility with a diagnosis of Urinary Tract Infection

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure a resident receives care, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing for one (1) of forty-six (46) sampled residents (Resident #142). The facility failed to ensure Resident #142's foot protectors were on both feet and a pillow or blanket was between the resident's knees, at all times to promote healing of a pressure ulcer to left foot.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections (UTI) to the extent possible for two (2) of forty-six (46) sampled residents (Residents #138 and #142). Observations of incontinent care for Residents #138 and #142 revealed staff failed to wash hands after removing used gloves after cleaning feces from each resident, and failed to wash hands prior to placing a clean brief on each resident.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to ensure one (1) of forty-six (46) sampled residents who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. Observation on 01/02/19 revealed the nurse did not check Resident #78's feeding tube for placement prior to flushing and administering medication per facility policy.

Inspectors wroteBased on observation, interview, record review, and review of facility policy and procedure, it was determined the facility failed to ensure a resident who needs respiratory care, including tracheostomy care, is provided such care, consistent with professional standards of practice and the comprehensive care plan for one (1) of forty-six (46) sampled residents (Resident #12). Observations on 01/04/19 at 8:40 AM, revealed staff failed to provide tracheostomy care for Resident #12, using aseptic (sterile) technique per facility policy and the resident's comprehensive care plan.

Inspectors wroteBased on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for one (1) of forty-six (46) sampled residents #78. Observation on 01/04/19 revealed a licensed staff failed to change her gloves and wash her hands before administering a flush/medications to Resident #78's peg tube after touching bed linens and repositioning the resident.