Redding Post Acute

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain food safety requirements regarding a clean and sanitary kitchen environment for food preparation for all residents who consumed food prepared by the kitchen when:1. The perimeter of the kitchen's walls at the height of the counters and below including pipes, drains, electrical coverings, and flooring were spackled with a filth buildup of food particles and adhered grime.2. The paint was chipped, peeling and worn out on walls, sink, and around flooring.3. The exterior of the stove/oven was unclean with cooked on grime.4. Rolling dollies with buckets of kitchen supplies were dirty with black filth.5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe environment for all residents who use the shower room when a spray bottle of bleach cleaner solution was observed in shower rooms one and two on wing three within unlocked cabinets above the toilets amongst toiletry essentials. This failure had the potential to result in physical injury and negatively impact the overall health for residents utilizing the common space. During a review of the facility's policy and procedure titled, Homelike Environment, dated February 2021, indicated, Residents are provided with a safe.environment. During a review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated Revised July 2017, indicated, Resident safety.and assistance to prevent accidents are facility wide priorities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six residents sampled (Resident 36), right to a dignified existence was protected when her eyeglasses were not clean. This failure could have resulted in a decrease in Resident 36's vision and emotional well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the care plan was revised for one of 18 sampled residents (Resident 6) when the care plan did not include the use of TED hose (tight socks that prevent swelling in the legs). This failure had the potential to cause severe leg swelling, delayed healing and an increased risk of blood clots, which could place this resident at risk for negative clinical outcomes. During a review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, dated April 2009, indicated, goals and objectives are reviewed and/or revised: when the resident has been readmitted to the facility from a hospital or rehabilitation stay. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe storage of medications for two of five residents sampled (Resident 64 and Resident 85) when:1. Resident 64's medications from home were stored in paper bags in a cabinet in the medication room (a locked room in a healthcare facility used to store, organize, and prepare medications).2. Resident 85's medication was stored loose in a medication cup (a small, disposable cup used for measuring and administering medications) in the medication cart (a wheeled cart used in healthcare to store, medications, and supplies). These failures could have resulted in lost medications or medication errors for Resident 64 and Resident 85.

Inspectors wroteBased on interview and record review, the facility failed to follow up and promptly report the results of an x-ray for one of three sampled residents (Resident 1) who were sampled due to falls in the facility when Resident 1 fell on her knee and her physician ordered an x-ray and the facility did not recognize they had not received the x-ray results for two days. This resulted in Resident 1 experiencing unnecessary severe left knee pain and a delay in treatment for two days due to a broken bone. This delay in treatment had the potential for Resident 1 to experience ongoing severe pain and negatively impact her physical, emotional, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the rights for one of three sampled residents (Resident 1) when Resident 1 did not receive a written notice of a proposed room change. This failure resulted in Resident 1 experiencing distress, frustration and the feeling of not having control over anything in her life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 (Resident #65 and Resident #72) of 19 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to initiate a Level I Preadmission Screening and Resident Review (PASRR) for a resident who received a psychiatric diagnosis, prior to readmission, for 1 (Resident #16) of 3 residents reviewed for PASRR.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of six residents who were sampled for quality of care (Resident 1), received care that was in accordance with professional standards and consistent with Resident 1's preferences and goals and at the level of assistance he needed. Resident 1 was admitted for Comfort Care (end of life care) on the afternoon of 9/14/24, and requested not to be put into a brief (adult diaper). During the night shift on 9/14/24, Certified Nursing Assistant (CNA) D had left Resident 1 in a soiled night gown, soiled brief, wet sheets, and the television (TV) in his room blaring and had not assisted Resident 1 in eating his supper. Resident 1 was found on 9/15/24 around 6:45 am, by his Family Member (FM) A and CNA C, in a soiled and soaking wet brief and hospital gown with dried brown rings on his bed sheets and the TV blaring. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food was prepared in a clean sanitary manner. This had the potential to cause food borne illnesses to the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program to provide a safe, and sanitary environment and to help prevent the transmission of infections with the census of 54 when: 1. Two out of two medication carts (a mobile cart used to store the medication and supplies for quick access for administration to residents) had unclean pill cutter (a small device that splits individual pills) shared among residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure house supply medications in the Central Supply Storage room (a storage room in the facility for non-prescription medications) were stored at a safe controlled room temperature in one out of three medication storage areas and a census of 54 residents. This failure could potentially cause medication to become ineffective if stored outside the manufacturer's recommended temperature guidelines.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their fall protocol, including updating the care plan and implementing interventions in the care plan, was completed to prevent falls, for one of four sampled residents, with a history of falls (Resident 4). This had the potential to result in a fall with serious injury.

Inspectors wroteBased on interview, and record review the facility failed to ensure resident's symptoms and distress were addressed on timely manner when existing nursing treatment and or medication did not improve the symptoms in one out of 17 sampled residents (Resident 52). This failure could contribute to unsafe care and/or resident's comfort level.

Inspectors wroteBased on interview, and record review the facility failed to ensure high risk anticoagulant medication (or blood thinner medication that may cause bleeding) was monitored on daily basis by nursing staff for possible adverse effects of the medication in one out of 17 sampled residents (Resident 28). This failure could result in unsafe medication use in the facility.