Cedar Crest Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drinks were served at a safe and appetizing temperature when cold drinks were served with a temperature higher than 41F (Fahrenheit, unit of measurement). This failure had the potential to discourage residents from increasing the amount they eat and drink. Resident census was 80.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper sanitation and maintenance of the ice bin (where ice is stored) when it was found to have black substances in the ice chute (ice dispenser), green substances on the corner edges, fine grayish particles on the exterior front, and was not cleaned according to the manufacturer's manual. Due to these systemic failures (as stated above) with potential to affect all residents and staff who uses and consumes ice from the ice bin, the facility needed to take immediate action to correct the noncompliance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. The filter of Resident 6's oxygen concentrator was dusty;2. Licensed vocational nurse M (LVN M) did not cleanse her hands before administering Pataday eye drops (allergy itch relief eye drops) to Resident 12;3. Licensed vocational nurse N (LVN N) did not cleanse her hands and change gloves before administering Fluticasone nasal spray (used to relieve allergy symptoms in the nose) to Resident 95; and4. Unlabeled personal care items in a shared bathroom by multiple residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain equipment in safe operating and sanitary conditions when:A bedside commode (a portable toilet, chair like structure to accommodate different user heights)'s metal pipe was found with dark brown patches and paint peeling off;Sink overflow drain hole area was found with black, white and dark brown spots in room C's bathroom;Lint filter and lint compartment with lint for dryer 1 and 2. The above failures had the potential to adversely affect the health and safety of residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was accessible and within reach for one of 20 sample residents (Resident 100). This failure had the potential to result in the resident's needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to protect resident's confidential personal care and medical information for five out of thirteen sampled residents (Resident 92, 96, 26, 45, and 10) when:Personal care instructions were posted visible to public for Residents 92, 96, 26, and 45;The computer screen was opened and unattended with Resident 10's protected medical information in a hallway. This deficient practice had the potential to compromise the privacy and confidentiality of above sampled residents.

Inspectors wroteBased on interview, and record review, the facility failed to accurately code the minimum data set (MDS: an assessment tool) for 1 of 3 sample resident (Resident 34) when Resident 34's MDS assessment did not reflect status of the resident. This failure had the potential to affect care and interventions for Resident 34.

Inspectors wroteBased on interview and record review, the facility failed to provide services that meet professional standards for two of 20 residents (8 and 102) when their physician orders for clonazepam (used to treat anxiety - feelings of fear, worry, nervousness, and unease) and trazodone (used to treat depression - a mental disorder that negatively affects how the persons feel, think, act, and perceive the world) did not have indication for the frequency of administration. This failure had the potential to result in Resident 8 and Resident 102 being overmedicated with medications capable of causing adverse effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate care and services for one of seven sampled resident (Resident 26) when Resident 26's foley catheter (F/C: a catheter which inserted into a bladder [a body organ that stores the urine] and remains in place to drain urine) drain tube was noted with bloody urine and there was no order to continue use of the F/C. These failures had the potential to result in urinary tract infection (UTI, an infection cause by a bacteria [germ] that get into the bladder) and ill effects on the health and well-being of Resident 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure intravenous (IV, refers to giving medicines or fluids through a needle or tube inserted into a vein) therapy was consistent with professional standards of practice and in accordance with physician orders when one (Resident 97) out of two sampled residents had an unlabeled IV site and had no longer Physician Orders for medications to be administered through IV.This failure had the potential to put Resident 97 at risk for complications related to intravenous therapy such as phlebitis (inflammation of the vein).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for two of five sampled residents (Residents 29 and 34) when:1. Facility staff did not post an Oxygen in use/No smoking sign on Resident 29's room entrance door;2. Resident 34's nasal cannula (NC, flexible tubing inserted into the nostrils and connected to an oxygen source) was not dated. These failures had the potential to compromise the residents' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 6 residents (6) was free from unnecessary medications when Resident 6 received morphine sulfate (used to treat pain) but was not monitored for the side effects and not care-planned on the use of the medication. This failure had the potential for the residents to experience unrecognized adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 8% when two medication errors occurred out of 25 opportunities during medication administrations for two out of seven residents (60 and 98). This failure resulted in medications not given in accordance with the prescriber's orders which resulted in residents not receiving the therapeutic effects of the medications and the residents' medications not accounted for.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure supplies were stored appropriately when expired incontinent wash bottle was found in the central supply room. This failure had the potential for the expired incontinent wash being used on the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to accommodate liquid consistency for one of five sampled residents (Resident 45). This failure had the potential for decreased meal intake, negative effect on health and well-being of Resident 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive, resident-centered care plans for six out of twenty-two sampled residents (Residents 37, 1, 53, 71, 41, and 2), when the activity care plans of Residents 37, 1, 53, 71, 41, and 2 were not comprehensive and resident-centered. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen utensils and equipment were maintained in good condition and stored in accordance with professional standards for safety when baking pans and magnetic knife holder were not kept in good working conditions. These failures had the potential to cause the growth of microorganisms, which could cause foodborne illness (illness caused by food or water contaminated with bacteria, viruses, parasites, or toxins) and cross contamination of food that could affect the 81 residents residing and consuming food at the facility.

Inspectors wroteBased on observation and interview it was found that the hospital's Quality Assessment Performance Improvement (QAPI) program was ineffective. Despite its purpose to proactively identify and prevent medication administration errors, it fell short. This was evident during a medication pass observation conducted during the survey, which revealed a concerning 13% medication error rate (See F759).

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to treat one of 22 sampled residents (Resident 390) with respect and dignity when Certified Nurse Assistant E (CNA E) was standing while feeding the resident. This failure had the potential to negatively affect residents' emotional and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to document the status of the resident's advance directive (AD, a written set of instructions, such as a living will or durable power of attorney, which is a document that authorizes to act on behalf of the resident for health care when the individual is incapacitated) for one of seven residents investigated (Resident 2). This failure had the potential for the resident's wishes to not be fulfilled, and not address.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the discharge Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 79). Failure to accurately assess had the potential to compromise the facility's ability to provide resident-centered discharge care planning and interventions for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for one of 22 sampled residents (Resident 390) when staff failed to ensure oxygen was administered as specified in the physician's order. This failure had the potential to compromise the residents' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to consistently complete the dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) communication form after dialysis for one of five residents (Resident 381) who received dialysis services. This failure had the potential to compromise the facility's ability to identify and address potential complications after dialysis.

Inspectors wroteBased on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, four medication errors were observed out of thirty opportunities for three of seven residents, resulting in an error rate of 13%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. One laundry staff did not perform hand hygiene before handling clean linens and residents' personal clothings; and 2. For Resident 381, staff did not perform hand hygiene during her treatment. These failures had the potential to spread infections, and compromise resident's health and safety in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received the necessary care and services for seven of 41 sampled residents (Residents 12, 11, 45, 66, 7 and 8) when: 1. Staff did not develop a personalized and resident-centered care plan, or document any follow-up treatment/skin reassessment when Resident 12 sustained a hematoma (a collection of blood, usually clotted, outside of a blood vessel that may occur because of an injury to the wall of a blood vessel) and cut on her right eyebrow. 2. Staff did not follow the physician's order to place floor/landing pad next to the bed when Resident 11 was in bed. 3. Staff did not follow the physician's order for bilateral heel floaters while in bed for Resident 45. 4. Licensed nurses did not follow the physician's orders for pain medication based on the residents' pain level for Residents 66 and 7. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control procedures when: 1. The nebulizer face mask and tubing for two Residents (24 and 28) were found undated and uncovered. 2. Licensed vocational nurse A (LVN A) did not perform hand hygiene and did not change gloves after touching potentially contaminated surfaces during the medication administration for Resident 42. 3. The two staff did not perform hand hygiene during dining observation. These failures put residents, staff and visitors at risk of possible spread of infection.

Inspectors wroteBased on interview, and medical record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) for two of 41 sampled residents (Residents 12 and 19), to reflect the fall incidents that occurred prior to the scheduled MDS assessment. MDS assessments should be accurate so as to provide the appropriate fall interventions to help prevent residents' further falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure an account of all controlled drugs was maintained and reconciled for 3 out of 4 randomly selected residents (Residents 66, 329 and 330) and, to ensure safe and effective use of medications for one of 18 sampled residents (Resident 32) when: 1. Three out of four randomly selected residents' (Residents 66, 329, and 330) controlled medication (those with high potential for abuse and addiction) records did not reconcile. The nursing staff signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but did not document on the Medication Administration Record (MAR) to indicate the controlled medications were given to the residents. This failure had the potential for misuse or diversion of controlled medications; and 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 18 sampled residents (Residents 17 and 43) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors, example is antipsychotics) when: 1. Resident 17 received quetiapine (brand name: Seroquel, antipsychotic medication) 50 milligrams (mg, unit of measurement) since 5/7/2019 without a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued); and there was no documented clinical rationale by the physician for why an attempted GDR was not indicated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had 7.69 percent medication error rate when two medication errors out of 26 opportunities were identified during the medication pass for one of five residents (Resident 42). These failures had the potential to result in an ineffective drug therapy and possible adverse events (such as side effects) for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label and store medications and biologicals when: 1. A bottle of lorazepam (anti-anxiety medication) oral liquid solution for Resident 42 was opened but not dated. 2. A vial of Tuberculin Purified Protein Derivative (to test for tuberculosis [TB]) was opened but not dated. 3. Two Systane eyedrops (Artificial Tears) were opened but not dated in medication cart #4. 4. A vial of Heparin (blood thinner to treat or prevent blood clots) injection solution was opened but not dated in medication cart #2. 5. Breo inhaler (medication for breathing problems) was open but not dated in medication cart #2. The deficient practice had the potential for the products to be used beyond the date they were safe and effective for use.