Redbank Center for Rehabilitation and Healing

In the surveyor’s words

From the most serious findings on record at Redbank Center for Rehabilitation and Healing, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF640Jan 11, 2023

  Based on interviews and review of pertinent facility documents, it was determined that the facility failed to complete and submit discharge Minimum Data Set Assessments (MDS), an assessment tool, as required for 17 of 17 residents (Resident #9, #17, #35, #47, #57, #82, #85, #93, #94, #96, #97, #98, #99, #100, #101, #102, and #110) system selected for MDS over 120 days and was evidenced by the following: On 1/4/23 at 10:32 AM, the surveyor interviewed the MDS Coordinator who stated she had been working alone on MDS for about five months, and the facility had been looking for additional help without success. At this time, the surveyor provided the MDS Coordinator with a list of thirty-seven system selected residents identified as having an MDS record that was over 120 days overdue. […]

• No harm, potential for more than minimal, widespreadF730Jan 11, 2023

  Based on interview and review of pertinent facility documents, it was determined that the facility failed to conduct yearly performance reviews of Certified Nursing Aides (CNA) in order to provide specific education based on the outcomes of the reviews. This deficient practice was identified for 4 of 4 CNAs whose personnel records were reviewed and was evidenced by the following: 1. According to the data provided by the facility, CNA #1 was hired on 9/11/08. Review of CNA #1's personnel file reflected there was no current performance evaluations completed for CNA #1. 2. According to the data provided by the facility, CNA #2 was hired on 11/5/14. Review of CNA #2's personnel file reflected there was no current performance evaluations completed for CNA #2. 3. […]

• No harm, potential for more than minimal, widespreadF801Jan 11, 2023

  Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to employee staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service in the role of the Food Service Director (FSD) in the absence of a full-time Registered Dietitian. This deficient practice would affect all residents and was evidenced by the following: On 1/3/23 at 9:24 AM, the surveyor entered the kitchen and asked to tour with the FSD. The Dietary Aide (DA) stated he was temporarily filling in for the FSD who has been out on leave since May. The DA stated he had no certifications in dietary management, food service management and safety or have a degree in food service management. […]

• No harm, potential for more than minimal, widespreadF812Jan 11, 2023

  Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure the dish machine in use maintained the appropriate temperature according to the manufacturer's specifications; b.) maintain multiuse food-contact surface cutting board in a manner to prevent microbial growth; c.) store, label, and date potentially hazardous foods to prevent food-borne illness; d.) discard potentially hazardous foods past their date of expiration; and e.) maintain storage areas in a sanitary manner. This deficient practice was evidenced by the following: On 1/3/23 at 9:24 AM, the surveyor entered the kitchen and asked to tour with the Food Service Director (FSD). […]

• No harm, potential for more than minimal, widespreadF881Jan 11, 2023

  Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the systemic implementation of their antibiotic stewardship program. This deficient practice was identified while reviewing Resident #29 for use of antibiotics for a urinary tract infection and has the potential to affect all residents. The evidence was as follows: On 1/3/23 at 12:02 PM, the surveyor observed Resident #29 lying in bed. The resident had a urinary catheter in a privacy bag that was positioned below the bladder. The surveyor reviewed the medical record for Resident #29. […]