Cedar Manor Nursing Home

Inspectors wroteBased on observations, facility policy review and staff interviews, the facility failed to provide a dignified eating experience for six of six resident's (Resident #21, 32, 38, 41, 43, 50) who ate their plated meals while they remained on a serving tray, The facility reported a census of 50 residents.

Inspectors wroteBased on observations, equipment manual review, resident and staff interviews, the facility failed to transport residents in the hallways in a safe manner for 2 of 2 residents (Resident #17 and Resident #53) reviewed for safety. The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, review of resident council minutes, facility policy review, resident and staff interviews, the facility failed to answer call lights within 15 minutes to meet resident needs for 2 of 2 residents (Resident #5 and Resident #49) reviewed for call lights. The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review the facility failed to provide the Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) to one out of three resident in a timely fashion (Resident#16). The facility reported a census of 50 residents.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure an indwelling catheter collection bag placed in a dignity cover, with the bag and bag remained off the floor to prevent urinary tract infections for one of one resident (Resident #39) reviewed with an indwelling catheter. The facility reported a census of 50 residents.

Inspectors wroteBased on observation, record review, resident and staff interview and facility policy review, the facility failed to properly document assessments for two of eight residents reviewed (Residents #2 and #3). The facility failed to document Resident #2's weekly wound assessments. In addition, the facility failed to document the time Resident #3's seizure lasted and failed to document follow-up assessments. The facility reported a census of 51 residents.

Inspectors wroteBased on observation, record review, resident, family and staff interview and review of facility policies, the facility failed to ensure the safety of 2 of 8 residents reviewed (Resident #1 and #5). Resident #5 fell while transferring with a Certified Nurse Aide (CNA). The fall resulted in 3 fractured ribs and a hemothorax (a condition where blood collects in the pleural space, the hollow area between lungs and rib cage). In addition, the facility failed to determine the cause of Resident #1's a facial bruise. The facility reported a census of 51 residents.

Inspectors wroteBased on medical record review, facility policy review, resident, family, and staff interview, the facility failed to treat two of eight residents reviewed with dignity and respect (Residents #1 and #5). The facility reported a census of 51 residents.

Inspectors wroteBased on observation, record review, staff interview and facility policy review, the facility failed to update Care Plans for three of eight residents reviewed. (Residents #1, #2, and #4). The facility failed to update the residents Care Plans after the staff discovered Resident #1 had an injury of unknown origin. After Resident #2 sustained burns to her thighs after she spilled coffee on her lap. Then after Resident #4 had a choking episode which required the Heimlich maneuver (first-aid treatment used to try to remove a blockage from someone's airway). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, staff, resident, and Advanced Registered Nurse Practitioner (ARNP) interviews, and facility policy review, the facility failed to administer the correct medication to 1 out of 7 residents reviewed, when a resident received another resident's medication in error (Resident #1). The facility reported a census of 48 residents. Findings Include: The Minimum Data Set (MDS) Assessment for Resident #1, dated 10/25/23, listed diagnoses of Atrial Fibrillation (Afib), coronary artery disease (CAD), heart failure, and hypertension (high blood pressure). The MDS reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The Care Plan for Resident # 1 dated 11/2/2023, identified altered cardiovascular status related to congestive heart failure and Atrial fibrillation. The Care Plan reflected interventions to include: a. [...]

Inspectors wroteBased on clinical record review, observation, staff interviews and facility policy review the facility failed to implement interventions to prevent the development of a pressure ulcer for a resident identified at risk for the development of pressure ulcers and failed to perform hand hygiene during wound care for one out of one resident reviewed for pressure ulcers (Resident #8). The facility reported a census of 44 residents. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of Pressure Ulcers: Stage I - An intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. [...]

Inspectors wroteBased on observations and staff interview the facility failed to transport leftover food items from the East Kitchenette down the hallway to the Main Kitchen in accordance with professional standards of practice for infection control and food safety, by not properly covering the food transported. The facility reported a census of 44 residents. Findings Include: 1. On 6/26/23 at 12:09 PM, the Dietary Staff observed transferring leftover food from the East Kitchenette down the facility hallway to the Main Kitchen on a three shelf wheeled cart. The leftover food containers noted to be uncovered with kitchen utensils still in the containers. Once inside the Main Kitchen the Dietary Staff discussed with the [NAME] about the leftover food. 2. On 6/27/23 at 12:11 PM, the East Kitchenette leftover food observed being returned to the kitchen by Staff A, Dietary Staff. [...]

Inspectors wroteBased on observation, staff interview and Dietary documentation review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety as evidenced during the brief Initial Tour of the kitchen and follow up visits to the kitchen. The facility reported a census of 44 residents. Findings Include: 1. On 6/26/23 at 9:53 AM, a brief Initial Tour of the Main Kitchen revealed the following concerns: a. A Vulcan gas stove with build up grim within the six burners of the stove. The back wall ledge of the stove approximately 3 inches in height noted with visible grime and grease across the length of wall. b. A Vulcan oven next to the stove had a build up of grime vertically streaked down the right side panel of the oven. The temperature dial, all oven door crevices observed to have grime and dust build up. c. [...]

Inspectors wroteBased on clinical record review, observations, resident and staff interviews and facility policy review the facility failed to report one out of one allegation of abuse to the state agency (Resident # 96). The faculty reported a census of 44 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews and facility manual review the facility staff failed to complete a Significant Change Minimum Data Set (MDS) Assessment when a resident developed a pressure area for 1 out of 1 residents reviewed with pressure sores (Resident #8) and when the same resident had a significant weight loss for 1 out of 12 residents reviewed for weight loss (Resident #8). The facility reported a census of 44 residents. Findings Include: The MDS Assessment for Resident #8 Dated 4/13/23, included diagnoses of non- Alzheimer's dementia, malnutrition, and altered mental status. The MDS revealed Resident #8 lacked pressure ulcers/wounds at the time of the MDS, and identified her risk for pressure ulcers. The MDS reflected Resident #8's weight at 137.8 pounds. [...]