RedBay Nursing and Rehab Center

Based on observations, interviews, and review of a facility policy titled Storage and Destruction of Medications, the facility failed to ensure the crash cart did not contain expired intravenous fluids and an expired prefilled syringe of normal saline. This was observed on one of five days of the survey, and had the potential to affect any resident who may have required treatment from the facility's crash cart. Findings include: A review of an undated facility policy titled Storage and Destruction of Medications revealed in part, Medication rooms, carts, and supplies should be locked or attended by those with authorized access only .Contaminated, deteriorated, or expired medications should be removed immediately and disposed of and reordered from the pharmacy (if applicable) according to policies. 1. An observation on 03/23/2022 at 7:35 PM revealed the facility's crash cart had a bag of 0.045% normal saline intravenous fluid that expired 09/2021 and was not in its original packaging. There was also a prefilled syringe of normal saline in the drawer that expired on 02/29/2020. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, document review, and interviews, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) after Resident Identifier (RI) #301, RI #39, and #21 were discharged from Medicare Part A services. Further, the facility failed to provide documentation of receipt of the Notice of Medicare Non-Coverage (NOMNC) by RI #301, RI #39, and RI #21 and/or their responsible parties. This affected three of three residents sampled for beneficiary protection notification review. Findings include: A review of a Face Sheet indicated the facility admitted Resident Identifier (RI) #301 on 08/11/2021. A review of a Notice of Medicare Non-Coverage document indicated RI #301's coverage would end on 11/08/2021. The form indicated RI #301 had met their maximum potential with therapy and a functional maintenance program had been put in place. This form was not signed to indicate the resident or the resident's responsible party had received and understood the notice. A review of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a clean, homelike, and orderly environment for Resident Identifier (RI) #48 and RI #29. Specifically, the facility failed to ensure: 1. Maintenance services were provided to address a non-latching door for room [ROOM NUMBER], and a difficult-to-latch door for RI #48. 2. RI #29's room was not used for storage for medical supplies not belonging to RI #29. This deficient practice affected RI #48 and RI #29, two of six residents reviewed during environmental observations. Findings include: 1. On 03/21/2022 at 8:40 AM and 8:51 AM, Resident Identifier (RI) #48 was observed exiting their room and had to slam the door to the room in order to get it to latch. On 03/21/2022 at 9:33 AM, Employee Identifier (EI) #32, Certified Nursing Assistant (CNA), entered the room to give the resident a milkshake. Upon exiting the room, EI #32 had to slam the door to get it to latch. On 03/22/2022 at 9:41 AM, Employee Identifier (EI) #28, Housekeeping Supervisor,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure nursing staff contacted the physician to obtain clarification orders to determine the most appropriate route of administration for Resident Identifier (RI) #8's Atropine eye drops, ordered to treat excess respiratory secretions. This deficient practice affected RI #8, one of one sampled resident reviewed for tracheotomy care and orders. Findings include: A review of RI #8's face sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Encounter for Attention to Tracheostomy, Anoxic Brain Damage, and Persistent Vegetative State. A review of RI #8's quarterly Minimum Data Set (MDS), dated [DATE], revealed RI #8 was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status. The MDS also indicated the resident was totally dependent on staff for activities of daily living (ADL) and required suctioning and tracheostomy care A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #33 was provided showers as scheduled. This affected one of two sampled residents reviewed for Activities of Daily Living (ADLs). Findings include: A copy of the facility's policy regarding ADLs/showers was requested from the facility. No policy was provided as of the exit date of the survey on 03/25/2022. A review of RI #33's face sheet revealed RI #33 was initially admitted to the facility on [DATE] and had a readmission date of 01/17/2017. RI #33 had diagnoses which included Alzheimer's Disease and Essential Hypertension. A review of RI #33's quarterly Minimum Data Set (MDS) dated [DATE] indicated RI #33 was severely impaired in cognitive skills for daily decision-making per a staff assessment of mental status. Also, according to this MDS, RI #33 was totally dependent on the assistance of two-plus people for transfers and bathing. A review RI #33's comprehensive care plans revealed a care plan dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews the facility failed to ensure Resident Identifier (RI) #29's PICC (Peripherally Inserted Central Catheter) line dressing was changed in accordance with professional standards of practice. This deficient practice had the potential to affect RI #29, one of one sampled resident reviewed for IV care. Findings included: A review of RI #29's Face Sheet indicated the facility re-admitted the resident from acute care on 03/11/2022 with diagnoses which included Sepsis due to Escherichia coli and Pressure Ulcer of Unspecified Buttock, Unstageable. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated RI #29 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive to total assistance of one to two people for all activities of daily living (ADLs), except for eating. A review of Physician's Orders dated 03/11/2022 through 03/31/2022 indicated RI #29…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of a facility policy titled Hand Hygiene, the facility failed to ensure: 1. Nursing staff washed their hands and changed gloves while providing tracheostomy (trach) care and suctioning for Resident Identifier (RI) #8; and 2. Staff performed appropriate hand hygiene during wound care for RI #29. These deficient practices affected RI #8, one of one sampled residents reviewed for tracheostomy care, and RI #29, one of three sampled residents reviewed for wound care. Findings include: A review of the facility's policy titled Hand Hygiene, dated 04/2020, indicated, .Appropriate hand hygiene should be performed: .b. Before performing resident care. c. Before performing invasive procedures .e. After having contact with a resident. f. After handling used dressings, specimen containers, contaminated tissue, linen, etc. [et cetera]. g. After contact with blood or other bodily fluids. h. Before and after glove use . l. After handling items or equipment that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview and review of facility policy titled, Refrigerator/Freezer Storage, the facility failed to ensure: 1. outdated food was not stored in the stand-up refrigerator/walk-in freezer; and 2. prepared food items were labeled with a use by date prior to storage in the walk-in freezer. These failures had the potential to affect 71 of 73 residents who received meals from the kitchen. Findings Include: The facility policy titled, Refrigerator/Freezer Storage with a last revised date of 11/08, included, Label all refrigerated food .by its use by date .Outdated food is to be discarded . On 08/26/19 at 4:01 p.m., the surveyor observed food items in the stand-up refrigerator. There was one plastic container of Puree Swedish Meatballs with an open date of 08/22/19 and use by date 08/25/19. On 08/26/19 at 4:18 p.m., the surveyor observed food items in the walk-in freezer. There was one box of popcorn shrimp with a receive by date of 03/11/18 and use by date 08/11/19, one box golden crisp corn nuggets with a receive by date of 10/15/18 and use by date 06/15/19 and one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and a facility document titled RESIDENTS-These are YOUR Rights, the facility failed to ensure Resident Identifier (RI) #32's catheter bag was covered with a privacy cover during the Resident Council Meeting on 8/27/2019 with 9 other residents in the room. This affected RI #32 one of two residents sampled with a catheter bag. Findings Include: A review of a facility document, RESIDENTS-These are YOUR Rights, with no date, revealed .Federal law requires us to treat YOU with dignity, privacy, . RI #32 was readmitted to the facility on [DATE]. A review of RI #32's physician order dated 2/22/19 revealed Foley Catheter 18 fr (french) with 30 ml (millimeter) bulb for urinary retention. On 8/27/19 at 10:05 a.m., the surveyor observed RI # 32 sitting in a wheelchair in the Resident Council Meeting in front of the dining room with 9 other residents in the room. The surveyor observed RI #32's catheter bag, without a privacy cover over the bag, attached to the left side of RI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, medical records, and a facility policy titled Handwashing, the facility failed to ensure a Licensed Practical Nurse washed her hands: 1. after giving Resident Identifier (RI) #63's oral medications, and prior to putting on gloves to give RI #63's eye drop medication, and 2. after administering RI #63's eye drop medication, removing her gloves, and prior to leaving RI #63's room, before opening the drawer of the medication cart. This affected one of three residents during medication pass and one of three licensed nurses observed during the mediation pass. Findings Include: A review of a facility policy titled Handwashing, with no date, revealed Purpose To provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infections . When to Wash Hands . 4. Before preparing of handling medication; . 9. After removing gloves; . RI #63 was admitted to the facility on [DATE]. A review of RI #63's medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, review of the facility's online reports to the State Agency, and review of the facility policy titled, Resident Abuse, the facility failed to ensure allegations of physical abuse were reported to the state agency within two hours. This affected 1 of 5 reports of abuse reviewed and involved 3 residents: Resident Identifier (RI) #25, #44 and #49. Findings Include: Review of undated policy tilted Resident Abuse documented: .VIII .8. If reportable .the facility will report the alleged event immediately not to exceed 2 hours if the events that cause the allegation involve abuse or result in serious bodily injury . 1) Review of the facility's online report to the state agency revealed the facility became aware of an allegation of physical abuse concerning RI #25 on 7/11/18 at 10:00 a.m The allegation of physical abuse was not reported to the State Agency until 7/11/18 at 2:02 p. m An interview was conducted with Employee Identifier (EI) #3, Director of Nursing (DON), Abuse Coordinator on 7/24/18 at 1:34 p.m. EI # 1 stated the incident of physical abuse involving RI #25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review and a facility policy tilted Comprehensive Care Plans, the facility failed to ensure a care plan for oxygen use was developed for Resident Identifier (RI) #62. This affected RI # 62, 1 of eighteen residents, whose care plans were reviewed. Findings Include: A review of a policy titled Comprehensive Care Plans with a revised date of November 2017 documented: .Purpose: To assure each resident has a Comprehensive Care Plan that is current, person-centered, and consistent with the medical regimen .8. The resident care plans are kept in the medical record .Residents who are readmitted to the facility .will have their previous Care Plan reviewed and revised as needed . RI # 62 was readmitted to the facility on [DATE] with diagnoses to include shortness of breath (SOB). A review of a Physician's Order Form for RI # 62 documented: .O2(oxygen) @(at) 2 liters per minute via (by) nasal cannula .4/23/18 . On 7/25/18 at 3:00 p.m., a review of Resident # 62 medical chart revealed no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and review of facility policies titled, Small Volume Nebulizer, Hand Washing and Oral Medications, the facility failed to ensure: 1. a Licensed Practical Nurse (LPN) rinsed with water and dried the mouthpiece and cup of the nebulizer after administration of Resident Identifier (RI) #6's nebulizer treatment, and 2. a LPN washed her hands, per facility policy, after having direct contact with RI #71, after removing gloves and after completion of medication administration to RI #71. The LPN further handled medications with her bare hands during the medication administration to RI #71. These deficient practices affected RI #6, one of one resident observed during a nebulizer treatment, and RI #71, one of three residents observed during medication administration, involved two of three nurses observed for medication administration. Findings Include: 1. A document provided by the facility addressing, E. Small Volume Nebulizer revealed, .Procedure: .Disassemble…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.