Redbanks Colonial Terrace

In the surveyor’s words

From the most serious findings on record at Redbanks Colonial Terrace, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF689Dec 2, 2022

  Based on interview, record review, review of facility policy, and the facility's initial investigation documentation, it was determined the facility failed to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of three (3) sampled residents (Resident #2). Interview with the Administrator on 12/01/2022 at 11:14, revealed on 11/27/2022 at 6:40 PM, Resident #2, proceeded to his/her room after a supervised smoke break with staff and went passed his/her room. Resident #2 approached door #1 on the northside of the building on Wing Two (2), where he/she pushed on the door until the magnetic locking system automatically disengaged. Resident #2 then exited the building without staff's knowledge. […]

• No harm, potential for more than minimal, isolatedF755Dec 2, 2022

  Based on observation, interview, record review, and review of the facility policies, it was determined the facility failed to establish a system of records receipt of medications, ensure drug records were in order, and account of all controlled drugs was maintained for two (2) of three (3) sampled residents (Resident #1 and Resident #6). Certified Medication Technician (CMT) #7 and Licensed Practical Nurse #1 failed to follow the facility's policy for counting narcotic medications when they did not count the narcotic medication at change of shift on the evening of 08/16/2022 and again on the morning of 08/17/2022. CMT #7 had Registered Nurse (RN) #1 count with him and they discovered Resident #6 had two (2) missing tablets of his/her Norco (a narcotic pain medication). […]

• No harm, potential for more than minimal, isolatedF880Dec 2, 2022

  Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of nine (9) sampled residents (Resident #9). Observation on 12/01/2022, revealed Certified Nurse Aide (CNA) #1 failed to wash her hands when providing care to Resident #9. The findings include: Review of the facility's policy titled, Handwashing, undated, revealed handwashing and hand antisepsis should be regarded by the facility as the single most important means of preventing the spread of infection. […]