EDWARDS REDEEMER HEALTH & REHAB

Nursing Home Inspector

1530 NORTHEAST GRAND BLVD
OKLAHOMA CITY, OK 73117
Oklahoma County
Phone: 405-424-2273
Provider Number: 375339
Last Inspection: 11/23/2016

About the Nursing Home

Number of Beds: 106
Number of Residents: 72
Beds Available: 34
Percent Occupancy: 68%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

115

Facility
30

County
26

OK
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

115

2016
49

2015
90

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

11/23/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Pattern : Minimal 4 12/12/2016
 
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Minimal 4 12/12/2016
 
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Pattern : Actual 5 12/29/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 12/6/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 12/12/2016
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Pattern : Minimal 4 12/16/2016
 
Failed To: Provide activities to meet the interests and needs of each resident. Pattern : Minimal 4 12/6/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 12/30/2016
 
Failed To: Provide adequate and comfortable lighting levels in all areas. Isolated : Minimal 3 12/29/2016
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 12/1/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 12/1/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 12/2/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 12/4/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Actual 5 3/4/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 12/15/2016
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 1/3/2017
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Immediate 5 1/3/2017
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Isolated : Actual 4 3/4/2017
 
Failed To: Make sure that doctors visit residents regularly, as required. Pattern : Minimal 4 12/30/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Immediate 5 1/3/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Pattern : Minimal 4 12/8/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 12/30/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 12/1/2016
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Pattern : Minimal 4 1/3/2017
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Widespread : Minimal 5 12/12/2016
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Pattern : Minimal 4 1/3/2017
 
Failed To: Keep complete, dated laboratory records in the resident's file. Pattern : Minimal 4 1/3/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 3/4/2017
 

9/30/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Isolated : Minimal 3 11/23/2015
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 11/23/2015
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 11/23/2015
 
Failed To: Provide adequate and comfortable lighting levels in all areas. Pattern : Minimal 4 11/23/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 11/23/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 11/23/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 11/23/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 11/23/2015
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 11/23/2015
 
Failed To: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Pattern : Minimal 4 11/23/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 11/23/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 11/23/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 11/23/2015
 

6/23/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 7/18/2014
 
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Minimal 4 7/18/2014
 
Failed To: Upon the death of a resident, convey the resident’s personal funds and an accounting of those funds to the appropriate party. Pattern : Minimal 4 7/18/2014
 
Failed To: Keep residents' personal and medical records private and confidential. Pattern : Minimal 4 7/18/2014
 
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Pattern : Minimal 4 7/18/2014
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 7/18/2014
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 9/17/2014
 
Failed To: Provide adequate and comfortable lighting levels in all areas. Pattern : Minimal 4 7/18/2014
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Pattern : Minimal 4 7/18/2014
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Pattern : Minimal 4 7/18/2014
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 7/18/2014
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 7/18/2014
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 7/18/2014
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Immediate 6 7/18/2014
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern : Minimal 4 7/18/2014
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 7/18/2014
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 7/18/2014
 
Failed To: Keep all essential equipment working safely. Pattern : Potential 3 7/18/2014
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Pattern : Minimal 4 7/18/2014
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 7/18/2014
 
Failed To: Put firmly secured handrails on each side of hallways. Pattern : Minimal 4 7/18/2014
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Widespread : Minimal 5 7/18/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

7/26/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Maintain comfortable and safe temperature levels. Pattern : Minimal 4 7/29/2017
 

7/5/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 7/11/2017
 
Failed To: Make sure that special or therapeutic diets are ordered by the attending doctor. Isolated : Minimal 3 7/11/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 7/11/2017
 

1/4/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide timely notification to the resident before transfer or discharge. Isolated : Minimal 3 2/2/2017
 
Failed To: Tell the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Isolated : Minimal 3 2/2/2017
 
Failed To: Establish and follow a written policy that permits a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Isolated : Minimal 3 2/2/2017
 

10/27/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Pattern : Actual 5 10/31/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Actual 5 10/31/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Actual 5 10/31/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 10/31/2016
 

7/6/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 8/19/2016
 

1/4/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 2/4/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Actual 5 2/4/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 2/4/2016
 

10/19/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Widespread : Minimal 5 11/23/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Widespread : Immediate 7 11/23/2015
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Widespread : Minimal 5 11/23/2015
 
Failed To: Operate and provide services according to Federal, State, and local laws and professional standards. Widespread : Minimal 5 11/23/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Widespread : Minimal 5 11/23/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 11/23/2015
 

9/30/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 11/23/2015
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Pattern : Actual 5 11/23/2015
 
Failed To: Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Pattern : Minimal 4 11/23/2015
 
Failed To: Dispose of garbage and refuse properly. Pattern : Minimal 4 11/23/2015
 
Failed To: Operate and provide services according to Federal, State, and local laws and professional standards. Pattern : Minimal 4 11/23/2015
 

6/19/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Pattern : Potential 3 7/3/2015
 

1/29/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 2/20/2015
 
Failed To: Try to resolve each resident's complaints quickly. Pattern : Minimal 4 2/20/2015
 
Failed To: Provide written records when a resident is transferred or discharged. Isolated : Minimal 3 2/20/2015
 
Failed To: Provide timely notification to the resident before transfer or discharge. Isolated : Minimal 3 2/20/2015
 
Failed To: Help and prepare each resident for a safe and easy discharge or transfer from the nursing home. Isolated : Minimal 3 2/20/2015
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Pattern : Minimal 4 2/20/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 2/20/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 2/20/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg OK State Avg
Number of Residents 72 74.85 61.05
Registered Nurses 0.23 0.61 0.47
Licensed Practical / Vocational Nurses 0.96 1.03 0.83
Certified Nursing Assistants 1.77 2.43 2.47
Total Staff Hours 2.96 4.07 3.77

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% OK State Avg%
of high risk long-stay residents with pressure ulcers 5 7 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 84 90 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 70 92 95
of long-stay residents experiencing one or more falls with major injury 6 4 5
of long-stay residents who have depressive symptoms 2 4 5
of long-stay residents who lose too much weight 4 7 8
of long-stay residents who received an antianxiety or hypnotic medication 35 26 29
of long-stay residents who received an antipsychotic medication 31 18 19
of long-stay residents who self-report moderate to severe pain 9 7 9
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 16 17 15
of long-stay residents whose need for help with daily activities has increased 14 15 15
of long-stay residents with a catheter inserted and left in their bladder 1 1 2
of long-stay residents with a urinary tract infection 2 3 5
of low risk long-stay residents who lose control of their bowels or bladder 22 41 34
of short-stay residents assessed and appropriately given the pneumococcal vaccine 70 80 79
of short-stay residents who had an outpatient emergency department visit 29 18 16
of short-stay residents who made improvements in function 44 60 64
of short-stay residents who newly received an antipsychotic medication 3 3 2
of short-stay residents who self-report moderate to severe pain 35 20 20
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 54 79 74
of short-stay residents who were rehospitalized after a nursing home admission 26 25 23
of short-stay residents with pressure ulcers that are new or worsened 3 48 48