Inspection Results » Edwards Redeemer Health & Rehab

Health Inspection on April 18, 2018 ^[1]

1. Pattern: Actual harm that is not immediate jeopardy

   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-05-24)

2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2018-05-24)
   • Respond appropriately to all alleged violations. (Corrected 2018-05-24)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-05-24)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (Corrected 2018-05-24)
   • Ensure residents have reasonable access to and privacy in their use of communication methods. (Corrected 2018-05-24)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2018-05-24)
   • Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. (Corrected 2018-05-24)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-05-24)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-05-24)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-07-23)
   • Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (Corrected 2018-05-24)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2018-05-24)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-05-24)
   • Honor the resident's right to organize and participate in resident/family groups in the facility. (Corrected 2018-05-24)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-05-24)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-07-23)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-05-24)
   • Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. (Corrected 2018-05-24)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-05-24)
   • Provide and implement an infection prevention and control program. (Corrected 2018-05-24)
   • Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne (Corrected 2018-07-23)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2018-07-23)
   • Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (Corrected 2018-05-24)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide activities to meet all resident's needs. (Corrected 2018-05-24)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-05-24)
   • Keep residents' personal and medical records private and confidential. (Corrected 2018-05-24)