Cedar Lake Health and Rehab Center

Inspectors wroteBased on interview and record review, the facility did not ensure allegations of abuse/neglect were reported to the State Agency (SA) for 1 resident (R) (R1) of 1 resident in a sample of 4 residents. R1 and their family filed a grievance with the facility on 3/26/26 that involved allegations of abuse/neglect. The facility did not report the allegations of abuse/neglect to the SA.

Inspectors wroteBased on interview and record review, the facility did not ensure care was provided in accordance with physician orders for 1 resident (R) (R2) of 4 sampled residents. R2's hospital discharge summary contained follow-up instructions for a right upper quadrant (RUQ) and left internal/external biliary drain to be flushed with 10 milliliters (ml) of saline twice daily. R2's medical record contained orders for a biliary drain and did not accurately reflect the orders. In addition, orders from an after visit summary on 5/4/26 indicated R2's biliary tube was attached to a bag after a tube exchange and the physician would tell them when to remove the bag and cap the drain. The orders were not transcribed into R2's medical record, were not clarified, and were not implemented.

Inspectors wroteBased on staff interview and record review, the facility did not review and revise the comprehensive plan of care for 5 residents (R) (R73, R61, R56, R21, and R68) of 8 sampled residents. R73 fell on 4/4/26. An intervention for a Posey grip on top of R73's wheelchair cushion was not added to R73's care plan. R61 fell on 4/13/26. A post-fall intervention was not added to R61's care plan. R56 had a specialty air mattress that was not reflected on R56's care plan or Kardex (an abbreviated care plan used by nursing staff) and staff did not check the functioning of the air mattress each shift. In addition, R21 and R68 had specialty air mattresses which were not reflected on their plans of care.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure allegations of abuse/neglect were thoroughly investigated for 4 residents (R) (R1, R2, R8, and R6) of 8 sampled residents. R1 reported an allegation of abuse involving Certified Nursing Assistant (CNA)-C. During the investigation, staff reported an allegation of abuse involving CNA-C and R2. The facility did not thorougly investigate the allegations of abuse. The facility's grievance file contained grievances from R8 and R6 that included allegations of abuse/neglect involving CNA-E. The facility did not provide staff education in an attempt to prevent further abuse or neglect.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure allegations of abuse/neglect were reported to the State Agency (SA) for 2 residents (R) (R6 and R8) of 8 sampled residents. R6 alleged that staff neglected R6 and left R6 in the bathroom without a call light for 30 minutes. R6 also alleged that staff used inappropriate language, threw a catheter bag across the room, and did not provide assistance when asked. The allegations of abuse/neglect were not reported to the SA.R8 alleged that staff neglected to provide care. The allegation of neglect was not reported to the SA.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to investigate an allegation of resident-to-resident abuse for 2 residents (R) (R4 and R3) of 3 residents reviewed for abuse.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the medical record was complete, accurate, and readily accessible for 1 resident (R) (R1) of 10 sampled residents. This failure had the potential for staff not to have knowledge about the resident and/or other residents residing in the facility.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 59 residents residing in the facility. The dry storage area, coolers, and freezer contained multiple open, undated, unlabeled, and/or expired items. Documentation logs for the parts per million (PPM) of the sanitizing solution in the sanitizing buckets and 3-compartment sink were not completed. Staff did not appropriately test and maintain dishwasher temperatures. Staff did not maintain a sanitary dishwashing practice.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Ombudsman was notified of a hospital transfer for 1 resident (R) (R52) of 1 resident. R52 was transferred to the hospital on [DATE]. The Ombudsman was not notified of R52's hospital transfer.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 2 residents (R) (R3 and R12) of 21 sampled residents who required assistance for activities of daily living (ADLs) were provided care in a timely manner. On multiple occasions from 1/1/25 to 2/19/25, staff did not answer R3 or R12's call lights or provide care in a timely manner.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R18 and R46) of 5 sampled residents were monitored for adverse reactions to high-risk medications. R18 was prescribed a fentanyl transdermal patch (an opioid medication) and oxycodone oral concentrate (an opioid medication) for pain. R18's plan of care did not contain monitoring interventions for adverse reactions to the high-risk medications. R46 was prescribed morphine (an opioid medication) and oxycodone (an opioid medication) for pain, spironolactone (a diuretic medication) for high blood pressure, and gabapentin (an anticonvulsant medication) for nerve pain. R46's plan of care did not contain monitoring interventions for adverse reactions to the high-risk medications.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a COVID-19 vaccine was administered for 2 residents (R) (R52 and R18) of 5 sampled residents. R52 and R18 were not administered a COVID-19 vaccine that R52 and R18's activated [NAME] of Attorney for Healthcare (POAHC) signed consent for.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 50 residents residing in the facility. The facility did not monitor and document food cooling temperatures. The facility did not monitor and document dishwasher surface temperatures. There were multiple open, undated, and/or expired food items in the dry storage area, and three coolers.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a CPAP (continuous positive airway pressure) machine was ordered by a physician and routinely cleaned for 1 Resident (R) (R13) of 19 sampled residents. The facility did not ensure R13 had a physician order for CPAP use and that R13's CPAP equipment was routinely cleaned per the facility's policy and the manufacturer's recommendations.