Redmond Care and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders for pain management and/or post-surgery staple removal were carried out for 2 of 4 Residents (Residents 1 & 2), reviewed for quality of care. These failures placed the residents at risk for discomfort and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were handled appropriately in accordance with professional standards of food safety for 32 of 75 residents (Residents 11, 3, 34, 128, 4, 178, 66, 28, 30, 33, 55, 182, 17, 51, 59, 36, 63, 74, 230, 183, 231, 44, 49, 7, 72, 52, 1, 13, 26, 53, 68 & 61), reviewed for food services. This failure placed the residents at risk of food-borne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) was obtained for 1 of 3 residents (Resident 14 ), reviewed for advance directives. This failure placed the resident and/or their representative at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice.

Inspectors wroteDISCHARGE STATUS RESIDENT 76 Review of the nursing progress notes printed on 06/09/2025 showed Resident 76 discharged home on [DATE]. Review of the discharge MDS dated [DATE] showed Resident 76 was admitted to the facility on [DATE] and was discharged on 03/15/2025. Further review of the MDS showed Resident 76 was marked they were discharged to the hospital in Section A2105 (Discharge Status). Section A2105 should have been marked discharge to Home/Community. In an interview and joint record review on 06/11/2025 at 11:09 AM, Staff D stated that they follow the RAI manual for completion of MDS assessments. A joint record review showed Resident 76's MDS dated [DATE] was marked discharged to the hospital. Staff D stated the MDS was marked discharged to the hospital and [Resident 76] did not go there. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan for 1 of 5 residents (Resident 3), reviewed for comprehensive care plans. The failure to implement the care plan for communication placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to maintain hearing methods to carry out the Activities of Daily Living (ADL) for 1 of 1 resident (Resident 3), reviewed for communication. This failure placed the resident at risk of not being able to hear and/or communicate and a diminished quality of life.

Inspectors wroteRESIDENT 14 An observation on [DATE] at 11:27 AM showed an opened bottle of biotin (a vitamin supplement) on Resident 14's nightstand. Resident 14 stated I try to take it [biotin] every day. Additional observations on [DATE] at 9:28 AM, on [DATE] at 9:17 AM, and at 1:12 PM, showed an opened bottle of biotin on Resident 14's nightstand. An interview and joint observation on [DATE] at 12:12 PM, Staff I, RN, stated that supplements were considered medications and that medications should be stored in a locked medication room or medication cart. When asked if medications could be stored at a resident's bedside, Staff I stated, No, [it] has to be in the cart. A joint observation showed an opened bottle of biotin on Resident 14's nightstand. Staff I stated that they were unsure if the opened bottle of biotin should be there. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene/glove use practices were followed for 1 of 4 staff (Staff J), reviewed for infection control. This failure placed the residents, visitors, and staff at an increased risk for infection and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure showers or bathing were consistently provided for 1 of 4 residents (Resident 1), reviewed for Activities of Daily Living (ADLs). This failure placed the resident at risk for poor hygiene, decreased self-esteem, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods stored were labeled/dated and discarded after the expiration date or use by date in accordance with professional standards for food safety for 1 of 3 freezers (Kitchen Walk-In Freezer) and 2 of 2 refrigerators (Kitchen Walk-In Refrigerator and Residents' Refrigerator), reviewed for food services. This failure placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker that met the educational requirements and supervised social work experience for one year in a health care setting for 2 of 2 social workers (Staff J & P), reviewed for social worker qualifications. This failure placed the residents at risk for unmet social services care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegation of abuse was reported to the State Agency for 1 of 3 residents (Resident 237), reviewed for abuse allegations. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plans for 2 of 18 residents (Residents 5 & 42), reviewed for comprehensive care plans. The failure to implement care plans for restorative care (to maintain a person's highest level of physical, mental, and psychosocial function to prevent decline that impact quality of life) and communication/sensory placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow up on hearing services for 1 of 2 residents (Resident 42), reviewed for communication and sensory. This failure placed the resident at risk for ineffective communication, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment free of accident hazards for 1 of 3 residents (Resident 76), reviewed for accident hazards. The failure to monitor and assess a sliding door as an exit, and to ensure a fence/gate that led to a parking lot and street was secured/locked, placed the resident at risk for elopement [form of unsupervised wandering that leads to a resident leaving the facility], injury, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain, label/date, and properly store oxygen nasal cannula (flexible tubing that sits inside the nose and delivers oxygen) for 1 of 1 resident (Resident 47), reviewed for respiratory care. This failure placed the resident at risk for unmet care needs, respiratory infections, and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene practices were followed before and after resident care and during meal tray pass for 1 of 13 staff (Staff I) reviewed for infection control. This failure placed the residents, visitors, and staff at an increased risk for infection and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods stored were properly covered, labeled/dated, discarded after the expiration date, or use by date and ensure ready-to-eat food was handled appropriately in accordance with professional standards for food service safety. These failures placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure bed-hold notices were provided at the time of transfer to the hospital for 3 of 4 residents (Residents 29, 124 and 26) reviewed for hospitalizations. This failure placed the residents at risk of lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 4 residents (Resident 71) reviewed for hospitalizations. The failure to ensure accurate assessment regarding discharge status resulted in inaccurate information in the resident's clinical record and placed the resident at risk for unidentified care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for 2 of 17 residents (Residents 51 and 36) reviewed for refusal of care/services, and 1 of 5 residents (Resident 26) reviewed for unnecessary medication. This failure placed the residents at risk for unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice to ensure physician orders were complete regarding the use of Lidocaine patch (a substance used to relieve pain by blocking signals at the nerve endings in skin) for 1 of 4 residents (Resident 13) reviewed for medication administration. The facility also failed to follow and clarify physician orders for 1 of 5 residents (Resident 69) reviewed for unnecessary medications. This failure placed the residents at risk for unmet care needs, potential negative outcomes, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bathing/shower and personal hygiene were consistently provided per their plan of care for 1 of 1 resident (Resident 124) reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for poor hygiene, decreased self-esteem, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the digestive system) was administered in accordance with physician's orders to accurately record the amount of enteral formula administered for 2 of 2 residents (Residents 68 and 69) reviewed for enteral nutrition. This failure placed the residents at risk for inadequate nutrition, hydration, and potential adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper care of a suction machine (a medical device used to remove mucus/saliva secretions/blood obstruction from a person's airway) including the suction tubing and suction canister for 1 of 1 crash cart (a medical device containing necessary equipment and supplies for use during emergencies). Additionally, the facility failed to store the Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) tubing and mask when not in use for 1 of 1 resident (Resident 13) and failed to ensure oxygen therapy was given according to physician's order for 1 of 1 resident (Resident 11) reviewed for respiratory care. These failures placed the residents at risk for unmet care needs, respiratory infections, and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 2 garbage dumpsters and 1 of 1 recycling dumpster were covered with a lid reviewed for outdoor garbage storage area. This failure placed the facility at risk of attracting bugs, rodents, and other germ carrying organisms (living things such as an animal or bacteria).