Redeemer Health Care Center

Inspectors wroteBased on observation and interview the facility failed to follow infection control standards of practice for cleaning of hard surfaces in the resident room for 1 of 1 residents. In addition, the facility failed to ensure personal laundry was transported and delivered in a manner that prevented risk of contamination for 1 of 3 hallways (3rd floor) observed for linen transportation. In addition, the facility had failed to ensure transmission-based precautions (TBP) were assessed for and implemented timely for 1 of 1 residents (R39) reviewed with symptoms of a possible gastrointestinal illness.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident and resident guardian's participation in the development of interventions for 1 of 1 resident (R44) reviewed for participation in care planning.

Inspectors wroteBased on interview and document review, the facility failed to ensure the physician was notified of a change in condition for 1 of 1 resident (R32) reviewed for a change of condition.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded with received medications to promote continuity of care and ensure accurate care planning for 2 of 2 residents (R122 and R311) reviewed for MDS accuracy.

Inspectors wroteBased on interview and document review, the facility failed to ensure a Level I Pre-admission Screening (PAS) and, if needed, a Level II Pre-admission Screening and Resident Review (PASARR) was completed to screen for mental health needs for 2 of 3 residents (R6, R32) reviewed for PAS.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine oral hygiene was completed to reduce the risk of complication for 1 of 4 residents (R39) reviewed for activities of daily living (ADLs) who were dependent on staff for their care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a developed skin condition was appropriately and consistently treated to promote healing for 1 of 2 residents (R49) reviewed who had developed dry skin.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper hand hygiene was completed for 3 of 4 residents ( R4, R5, R6). In addition, the facility failed to ensure proper personal protective equipment (PPE) was properly utilized for 1 of 4 resident (R4) reviewed for infection control.

Inspectors wroteBased on interview and document review the facility failed to ensure the Quality Assurance Process Improvement (QAPI) committee was effective in maintaining appropriate action plans to correct a quality deficiency identified during a previous survey related to self administration of medications (SAM) which resulted in a deficiency identified during this survey.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper hand hygiene was completed during medication administration for 2 of 4 residents ( R41, R48). The facility also failed to ensure proper hand hygiene was implemented during suprapubic (S/P) catheter cares for 1 of 4 residents (R2), and during the provision of personal cares for 1 of 4 residents (R88) reviewed for infection control. Additionally, the facility failed to ensure proper personal protective equipment (PPE) was utilized for 1 of 1 resident (R266) reviewed for enhanced barrier precautions. Findings Include: Medication Administration R41's quarterly Minimum Data Set (MDS) dated [DATE], indicated R41 was cognitively intact. R41's face sheet diagnosis included other sites of candidiasis, urinary tract infection. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self administration of medications (SAM) assessment was completed to allow residents to safely administer their own medications for 3 of 3 (R66. R6, and R73) residents observed with medications at bedside.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the call light was accessible for 1 of 1 resident (R39) reviewed for accommodation of needs.

Inspectors wroteResident #83 Based on interview and document review, the facility failed to contact the designated representative and gain consent for medical treatment for 1 of 1 residents (R83) reviewed for notification of change.

Inspectors wroteBased on observation, interview, and document review, the facility failed to draw privacy curtains or close the residents door during personal cares, making a resident feel their personal privacy was not being protected for 1 of 1 resident (R1) reviewed for personal privacy and confidentiality.

Inspectors wroteBased on interview and document review, the facility failed to ensure a baseline care plan was reviewed and provided timely to ensure knowledge of care and promote person-centered care planning for 1 of 2 residents (R74) reviewed for care planning.

Inspectors wroteBased on observation, interview, and document review, the facility failed to accurately assess and monitor multiple non-healing and bleeding skin lesion, lacerations, and scabs for 1 of 1 resident (R40) reviewed for non-pressure related skin conditions.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assure properly operational pressure-reducing air mattress were in place as intervention to reduce pressure ulcers for 2 of 3 residents (R39 and R87) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure post-dialysis assessment and monitoring was completed for 1 of 1 residents (R40) reviewed for dialysis.

Inspectors wroteBased on interview and document review, the facility failed to provide medically related social services and/or obtain mental health counseling for 1 of 1 resident (R87) diagnosed with major depressive disorder and inappropriate tendencies towards staff reviewed for behavioral services.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure comprehensive trauma assessments were completed to ensure appropriate treatment and services for 6 of 6 residents (R1, R2, R3, R4, R5 and R6) who had a history of traumatic events.

Inspectors wroteBased on interview and document review, the facility failed to implement a comprehensive infection control program to include tracking of infections, illness with timely surveillance data and a comprehensive analysis which identified interventions when patterns and trends were identified to reduce the risk of spreading infections to other residents. This had the potential to effect all 111 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to implement a comprehensive antibiotic stewardship program with established monitoring to help reduce unnecessary antibiotic use, reduce potential drug resistance, ensure appropriate antibiotics were utilized to prevent antibiotic resistance and help prevent the spread of infectious diseases. This deficient practice had the potential to affect all 111 residents residing at the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide routine personal grooming and cleanliness for 1 of 2 residents (R31) reviewed for activities of daily living (ADLs) who were dependant on staff for their care.

Inspectors wroteBased on interview and document review, the facility failed to assess and manage resident symptoms at a level consistent with the current professional standards of practice for 1 of 1 residents evaluated for loose stools.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure prescribed medication was not left unattended in resident room, for 1 of 1 resident, (R89), who was observed to store narcotic medication in room, and not monitored for medication administration.