Redlands Comm Hosp D/p Snf

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Resident 4's Enhanced Barrier Precautions (EBP-an infection control guideline that requires staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading infectious diseases) protocol were not followed in accordance with facility's policy and procedure (P&P). 2. One glucose monitoring (a device used to measure the amount of sugar (glucose) in the blood) device was found visibly soiled with dried white substance while docked (recharged) at the nurse's station. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to 7 medically compromised residents and staff in the facility.Findings: 1. During a review of Resident 4's Record of Admission (contains demographic and medical information), undated, the Record of Admission indicated Resident 4 was…

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 and record review, the facility failed to ensure the nursing staff provided treatment appropriately for one of seven sampled resident (Resident 18) when the nursing staff did not check Resident 18's blood glucose (sugar) daily as ordered. This failure resulted in Resident 18 inadequately monitored for blood sugar, which had the potential to cause uncontrolled blood sugar and negatively affect Resident 18's health and safety.Findings: During a review of Resident 18's admission Records (contains demographic and medical information), undated, Resident 18 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of female breast (breast cancer, abnormal cells in the breast grow uncontrollably and form a tumor), metastatic cancer to the spine (cancer cells traveled from the breast and formed new tumors in spine bones), and diabetes mellitus type II (a condition where the body cannot control blood sugar). During an interview on December 1, 2025, at 10:21 AM, with…

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 observation, interview, and record review, the facility failed to post facility name, and the total number and the actual hours worked per shift for licensed and unlicensed staff daily. This failure resulted in residents, family, and staff being unable to see if the unit is staffed appropriately.Findings: During a concurrent observation, interview, and record review on December 3, 2025, at 5:51 AM in the Transitional Care Unit (TCU) with the Registered Nurse (RN 1), the in-unit staffing list (a posted list visible to residents, family, and staff, that outlines how many hours all patient care staff classifications are working during a given shift) was posted on a television monitor. The television did not show the facility's name, or the actual hours worked per shift for licensed and unlicensed staff. The RN 1 stated the Direct Hours Per Patient Day (DHPPD)(the average number of hours per day that nursing staff spend providing hands-on care to each resident in a facility) is not posted anywhere in the unit. During a concurrent interview and record review on December 4, 2025,…

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, and record review, the facility failed to ensure drugs and biologicals were properly labeled for one of three sampled residents (Resident 7) when the gastrostomy tube (G-Tube-a soft tube placed through the skin directly into the stomach) formula bottle (a bottle premixed medical nutrition formula used for tube feeding to provide calories, proteins and nutrients when a resident cannot eat by mouth is given by the stomach) was not labeled with nurse initials and the water flush bag (a water bag used to deliver scheduled water flushes though the feeding tube to maintain hydration and keep the tube clear) was not labeled with the prescribed rate as required. These failures placed Resident 7 at risk for receiving incorrect formula, improper feeding rates, or inadequate hydration, which potentially resulting in dehydration, electrolyte imbalance, aspiration (chocking), and compromise nutrition. Findings: During a review of Resident 7's Patient Demographics (contains patient…

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 and record review, the facility failed to ensure the successful electronic submission of complete and accurate direct care staffing information was transmitted to Centers for Medicare and Medicaid Service (CMS) for two quarters (May 13, 2025, and August 14, 2025). This failure resulted in the facility not being monitored for any potential staffing issues.Findings: During an interview and record review on December 3, 2025, at 8:55 AM, with the Director of Nursing (DON), the CMS Submission Report (various mandatory reports such as payroll based journal (PBJ) or staffing data based on payroll) for the 2025 quarters were reviewed. The DON stated, The PBJ is supposed to be submitted quarterly. I thought it went through, but it did not due to issues with our system, [Name of Company]. The DON further stated, The PBJ Submission on May 13, 2025, and August 14, 2025, were submitted to CMS but our [Name of Company] we used erased the information because of the wrong code so it was transmitted with no staffing information. The DON further stated, It's important that…

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, and record review, the facility failed to ensure residents were treated with respect and dignity in an environment that enhances quality of life for two of five sampled residents (Residents 55 and 56) when lunch was served in a plastic bag with disposable plastic container and utensils and no placemat, tray or plate were provided. This failure resulted in Residents 55 and 56 not having a place to set their food when eating and having to place some items on the table when preparing their meal to eat which had the potential to negatively impact the residents' mental and psycho-social well-being. Findings: 1a. During a review of Resident 55's History and Physical (H&P-contains resident's medical history, physical examination and reason for admission to the facility), the H&P indicated, Resident 55 was admitted on [DATE], for physical therapy (PT-a treatment method where physical methods as massage, heat treatment and exercise are used rather than by drugs or surgery) and…

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 and record review, the facility failed to ensure the quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) was completed and submitted to CMS in accordance with federal submission timeframes, for one of six reviewed for resident assessment (Resident 1). This failure resulted in inadequate monitoring of progress or decline for Resident 1 and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: During a review of Resident 1's History and Physical (H&P -contains resident's medical history, physical examination and reason for admission to the facility), the H&P indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus ( a disease that causes your blood sugar to be too high), end stage renal disease (ESRD - kidney failure) and osteomyelitis (an…

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 and record review, the facility failed to follow policy and procedure (P&P) for four of five residents when: 1. Staff failed to perform hand hygiene during medication administration and having direct contact with three residents (Resident 55, 56, and 106). 2. Intravenous (IV-into the vein) tubing was not used according to standards of practice for one resident (Resident 57) when the facilities policy and procedure (P&P) for IV therapy was not updated. These failures had the potential to place patients at a greater risk for spreading of infection from cross-contamination (the transfer of harmful bacteria) causing a preventable bloodstream infection, and negatively impact residents' health and safety. Findings: 1a. During a review of Resident 106's Admitting Form (a demographic data about the resident), the Admitting Form indicated, Resident 106 was admitted to the facility on [DATE], for physical therapy (PT-a treatment method where physical methods as massage, heat treatment and…

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 observation, interview, and record review the facility failed to maintain a sanitary kitchen in accordance with professional standards for food safety when: 1. In the kitchen entrance, there was no available hair restraints (such as hair nets and beard restraints) for kitchen staff and visitors to use. 2. Three kitchen staff, who had beards, were not wearing beard restraints while working inside the kitchen. These failures had the potential to cause foodborne illnesses to 8 medically compromised residents who receive food served by the kitchen. Findings: During a concurrent observation and interview, on November 13, 2023, at 8:29 AM, with the Kitchen Manager (Manager 1), the kitchen entrance was inspected. There was no available hair nets and beard restraints for staff and visitors to use upon entering the kitchen. The Manager 1 acknowledged the findings, and stated hair nets and beard restraints should be easily accessible near the kitchen entrance door. During a concurrent observation and interview, on November 13, 2023, at 9:20 AM, with the Associate Chef (Chef 1), in…

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.