Cedar Ridge Center

Inspectors wroteBased on observations, resident interviews and staff interviews the facility failed to ensure a safe clean and homelike environment. Various cosmetic imperfections were found and two (2) residents did not have bed linens. These were random opportunities for discovery and have the potential to effect more than an isolated number of residents. Room identifiers: #15, #16, #24, #28, #32, #33, #35, #36, #37, #39, and #42. Resident identifiers: #76, and #130. Facility Census: 115. a) A facility walk through on 06/17/26 at 10:35 AM, with the facility administrator found and confirmed the following environmental issues in Resident Rooms #15, #16, #24, #28, #32, #33, #35, #36, #37, #39, and #42: b) room [ROOM NUMBER]: The caulking around the sink and countertop was cracked with missing pieces and had dark, discolored debris buildup. [...]

Inspectors wroteThe facility failed to revise care plans for Resident #115 and Resident #11 and failed to ensure an interdisciplinary approach to care planning for Resident #91. Resident identifiers: #115, #111 and #91. Facility census: 115.

Inspectors wroteBased on record review and staff interview the facility failed to follow physician's orders to ensure residents received proper treatment and care to maintain mobility. This was true for one (1) of one (1) residents reviewed related to positioning and wearing splints/orthotics. Resident Identifiers: Resident # 10. Facility Census: 115. Findings Included: a) Resident #10 Resident #10 has a diagnosis code of M24.571, which is a contracture of the right ankle. Resident #10 has orders that state Medex boots to Bilateral Lower Extremity (BLE) licensed nurse to remove and assess skin integrity every shift. It was observed on 06/18/2026 at 12:05 PM no boots were on Resident #10. The Treatment Administration Record (TAR) reviewed for June 2026 revealed that the assessment was done and boots removed at the following times: 01:17, 10:40, and 19:05. This was signed off by Employee #67. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. There was an issue with lawncare equipment that could potential injure a resident being present and accessible to residents in the courtyard and a screw protruding through the arm rest on a resident's wheelchair. Resident identifiers: #34 and #102. Facility Census: 115.

Inspectors wroteBased on record review, policy review, resident interviews and staff interviews, the facility failed to ensure all food was temped before leaving the kitchen, to ensure safe and appetizing temperatures of the food to prevent foodborne illness. The facility failed to ensure all foods were palatable. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #14 and #63. Facility census: 115Findings include: a) Healthcare Services Group (HCSG) policy #6 titled Food Quality and Palatability stated: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive, and served in a manner, form, and texture to meet resident's needs. Proper safe and appetizing temperature: [...]

Inspectors wroteBased on record review, resident interviews and staff interviews, the facility failed to provide food that accommodates resident preferences and appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice. Resident identifiers: #32, #40 and #9. Facility Census: 115. Findings Included: a) Dining and Food Preferences policy statement:During a record review of the facility dining and food preference policy statement #8 indicated Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverages will be offered an alternative selection of comparable nutrition value. and policy statement #9 stated The alternative meal and/or beverage selection will be provided in a timely manor. [...]

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional food safety standards. Additionally, the facility failed to follow proper sanitation practices for the kitchen. This practice had the potential to affect more than a limited number of residents. Facility census:

Inspectors wroteBased on observation, record review, policy review, and staff interviews, the facility failed to store and dispose of garbage and refuse properly. Trash was found on the sidewalk outside the facility service entrance. The lid for the kitchen trash can was off during three (3) different observations of the kitchen, during the survey process. This failed practice had the potential to affect more than a limited number of residents at the facility. Facility census: 115.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure the medical record was complete and accurate. This was true for four (4) of 41 sampled resident reviewed during the long term care survey. Resident #10's medical record was inaccurate pertaining to Medex Boots. Resident #11's medical record was inaccurate pertaining to a left arum support cushion. Resident #101 and #117's medical record was inccurate pertaining to amount of house supplement consumed. Resident Identifiers: #101, #117, #10, and #11. Facility Census: 115.

Inspectors wroteBased on observation, policy review and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections regarding resident ambulatory equipment and the screening for tuberculosis. This failed practice was a random opportunity for discovery. Resident identifiers: #102, #126, #37, #110, #36 and #98. Facility Census:

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health. This was true for Two (2) of Two (2) residents reviewed related to foot health. Resident Identifiers: Resident #27 and #22. Facility Census: 115.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration each resident's preferences and physician's orders. Resident identifier: #22. Facility census:

Inspectors wroteBased on record review, staff interview and resident interview the facility failed to provide necessary safety to a resident who eloped the facility. Resident #18 eloped from the facility on 03/08/26 at approximately 9:00 AM. No action was taken by the facility until 1:30 PM, although a staff member seen Resident #18 walking down the street at approximately 9:00 AM. This neglectful practice placed Resident #18 in immediate risk for serious harm and or death. Resident identifier: #18 Facility Census: 113. The State Agency (SA) determined the facility's failure to act on a known elopement resulted in an Immediate Jeopardy situation when: staff witnessed Resident #18 walking down a public street at approximately 9:00 AM on 03/08/26 but failed to intervene or report the sighting. [...]

Inspectors wroteBased on record review, staff interviews, family interviews, and resident interviews, the facility failed to provide care and services in accordance with professional standards of practice. Resident #46 was walking with Restorative Therapy, without a Gait belt and fell. The State Agency (SA) determined harm occurred to Resident #46; the fall resulted in a break in her left femur and a fracture below her right knee. This failed practice was found true for (1) one of (1) one residents reviewed for falls during the complaint survey process. Resident identifier #46. Facility Census: 113. Findings Include:a) Resident #46A record review on 03/17/26 at 9:30 AM, revealed that Resident #46 had a fall on 02/18/26 and was sent to a local emergency room for pain to her right and left legFurther record review of the Diagnostic Radiology reports from the hospital showed the following:Left Femur: [...]

Inspectors wroteBased on observation, resident interview, staff interview and record review the facility failed to ensure Resident #46 received ongoing opportunities to participate in meaningful activities consistent with her interests, and preferences. Specifically, following a significant change in condition after a fall resulting in multiple fractures, the facility failed to revise the resident's activity care plan and failed to provide consistent, individualized activity interventions. This resulted in a decline in activity participation and social isolations. This failed practice was found true for (1) one of (1) one residents reviewed for quality of life during the complaint survey. Resident identifier #46. [...]

Inspectors wroteBased on a record review and staff interviews, it was determined that the facility failed to provide a 30-day discharge notice to a resident prior to their discharge. This failed practice had the potential to affect a minimal number of residents within the long-term care facility. Resident identifier: #98 Facility Census 113.

Inspectors wroteBased on record review, and staff interview the facility failed to update an activity care plan after Resident #46 had a significant change in her participation. This failed practice was found true for (1) one of (1) one residents reviewed for activities during the complaint survey process. Resident identifier #46. Facility Census 113. Findings Include:a) Resident #46A record review on 03/17/26 at 9:30 AM, revealed Resident #46 had a fall on 02/18/26 and was sent to a local emergency room for pain to her right and left legFurther record review of the Diagnostic Radiology reports from the hospital showed the following:Left Femur: Anterior apex angulated fracture of the distal femur diametaphyseal fracture with impaction. Right Knee: Impaction and comminuted anterior apex angulated fracture distal fifth metaphysis present. Osteopenia noted. [...]

Inspectors wroteBased on record review, staff interview, and resident interview the facility failed to provide a program of activities to meet the interest and needs of Resident #46 who has had a significant change in her activity participation. This failed practice was found true for (1) one of (1) one residents reviewed for activities during the complaint survey. Resident identifier #46. Facility Census: 113. Findings Include:a) Resident #46A record review on 03/17/26 at 9:30 AM, revealed that Resident #46 had a fall on 02/18/26 and was sent to a local emergency room for pain to her right and left legFurther record review of the Diagnostic Radiology reports from the hospital showed the following:Left Femur: Anterior apex angulated fracture of the distal femur diametaphyseal fracture with impaction. Right Knee: Impaction and comminuted anterior apex angulated fracture distal fifth metaphysis present. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to manage pain in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of pain. Resident Identifier: #14. Facility census: 117.

Inspectors wroteBased on observation and food tray temperatures, the facility failed to serve food to residents that was palatable and at an appetizing temperature. Based on resident interview and staff interview, the facility failed to ensure hot foods were served hot and cold foods were served cold. This failed practice was true for one (1) of one (1) hallways tested for food tray temperatures throughout the complaint survey process. Resident #35. Facility census: 117.

Inspectors wroteBased on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect more than an isolated number of residents. Facility census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to provide accurate and complete medical records for four (4) of 24 residents reviewed in the long-term care survey sample. Transfer assessments were not accurate for Residents #78 and #7. Tube feeding documentation was not accurate for Resident #47. Additionally, the activities assessment for Resident #21 was not completed by a qualified staff member. Resident Identifiers: #78, #7,#47, and #21. Facility census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to complete the quarterly assessments for restraint usage for Resident #6. This was true for one (1) of one (1) residents reviewed under the care area of restraints. Resident Identifier: #6. Facility Census: 117. Findings Include: a) Resident #6 On 02/18/26 at 8:30 AM, a record review was completed for Resident #6. The review found the following physician's order dated 04/22/25, Restraint: Positioning device/belt to w/c (wheelchair) while up in w/c for dx (diagnosis) of Cerebral Palsy and involuntary movements of core/ trunk area. Release device/belt every 2 (two) hours for repositioning every 2 (two) hours for seat belt to chair. Also, the review found the last restraint evaluation/reduction was completed on 05/29/25. The evaluation/reducation should be completed quarterly. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to develop a comprehensive care plan for one (1) of 24 residents reviewed in the long-term care survey sample. Resident identifiers: #3. Facility census: 117.

Inspectors wroteBased on record review and staff interviews th facilty failed to revise care plans related to one (1) on one(1) activities and PEG tube length. This failed practive was found true for two (2) of 24 residents care plans reviewed during the Long Term Care Survey Process. Resident identifiers: #50 and #47. Facility Census: 117Findings include: a) Resident #50 On 02/16/26 at 11:27 AM a Review of the participation record for Resident #50 showed most activities Provided were one-on-one activities. further record review of Resident #50's care plan revealed nothing in the care plan for Resident #50 to receive one (1) on (1) activities. Record review completed on 02/17/26 Revealed the one (1) on one (1) list provided from Activity Director (AD) #14 showed the resident was on the one (1) on one (1) program list to receive one (1) on one (1) activities. [...]

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to follow a physician's order for oxygen settings for Resident #20. Facility census 117. a) Resident #20. Based on observation, interview, and record review, the facility failed to ensure services were provided in accordance with physician orders. Specifically, the facility failed to ensure oxygen was administered at the ordered rate. On 02/18/26 at 9:19 a.m., observation of Resident #20 revealed oxygen delivered via nasal cannula at 4 liters per minute. Record review of the physician's orders indicated an active order for oxygen at 2 liters per minute via nasal cannula. On 02/18/26 at 9:19 a.m., interview with Nurse #111 confirmed the oxygen was set at 4 liters per minute and verified the current physician order was for 2 liters per minute. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the posted daily nurse staffing information was accurate for one (1) of 20 days reviewed, resulting in incorrect staffing and census information being displayed. Facility Census: 117Findings include:Review of the facility's nurse staffing posting on 02/18/26 for staffing dated 07/06/25 showed the posted Hours Per Patient Day (HPPD): 2.19 and the posted facility census: 109 residentsDuring surveyor review, the facility administrator provided verified staffing documentation and census reports showing actual HPPD for 07/06/25 was 2.58 and actual facility census for 07/06/25 was 105 residentsDuring an interview the discrepancies were reviewed with the facility administrator On 02/19/26 at 11:00 AM when the administrator confirmed the staffing posting contained incorrect HPPD and census information.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the residents received the proper portion sizes. This failed practice has the potential to affect more than an isolated number of residents and was a random opportunity for discovery found during the completion of the dining observation pathway during the long-term care survey process. Resident #44 and #91. Facility Census: 117.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, the facility failed to ensure that the resident's received a therapeutic diet for a renal diet and the 2 gram sodium diet. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers: #42, #56, #80, #78, #132, # 90, #98, #105 and #117 . Facility census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate comprehensive care plan in the area of medication refusals. This deficient practice had the potential to affect one (1) of three (3) residents in the survey sample. Resident Identifier: #111. Facility Census: 110.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. Psychiatric telemedicine notes contained an inaccurate history of present illness (HPI) for Resident #111. This was a random opportunity for discovery. Resident Identifier: #111. Facility Census: 110.

Inspectors wroteBased on observation and staff interviews, the facility failed to maintain an environment free of accident hazards for 1 out of 26 residents. Facility census 112. Scope and Severity D On 11/11/25 at approximately 11:07 p.m., observed a medicine cup with 1 pill in it located on the bedside table of resident #8. I then notified the Director of Nursing (DON) to come to the room and verify that there was a medication cup with 1 pill in it on the bedside table. The DON verified that the medication cup was on resident #8 bedside table. The DON and myself went and checked 26 residents (Rms 1-16) and there was only 1 out of 26 residents that had the medication cup with meds left at their bedside. The DON verified that medication pill pass was performed by employee # 81. The medication identified was a 1/2 tab of Senokot. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that narcotics in the facility were managed and controlled in a safe manner. This is true for eleven (11) of eleven (11) residents reviewed during the survey. All residents that receive pain medication in the facility have the potential to be affected. This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning. This did occur, however due to the facility identifying the missing medications and replacing them immediately for the Residents that remained in the facility no Residents were harmed by this incident. Resident Identifier: #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12. Facility Census: [...]

Inspectors wroteBased on record review and staff interview the facility failed to complete all Physicians orders for wound treatment. This was true for one (1) of three (3) residents reviewed during this investigation. Resident Identifier: #1 Facility Census: #112 Findings Include:a) Resident #1On 10/16/25 at 9:10 AM record review of Resident #1 orders and Treatment Administration Records (TAR) for August, September and October 2025 found missing documentation as shown below. All orders and TAR's were reviewed for the period of 08/01/25 - 10/31/25. None of the following Physician orders were completed on 10/09/25, 10/16/25, 10/21/25 or 10/22/25. Clean DTI (deep tissue injury) to left buttocks with wound cleaner, pat dry, apply skin prep to area and leave open to air every day shift. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure Resident #31, #37, #105 and #53 had an accident-free environment. Excessive gaps were found with no gap fillers at the foot of three (3) residents' beds. One (1) resident had his arm entrapped between the mattress and side rail. Excessive gaps in danger zones on a resident bed can lead to serious injuries including death. This created an immediate jeopardy situation that began on 05/13/25 at 10:00 AM and ended on 05/14/25 at 12:00 PM. Resident identifiers: #31, #37, #105 and #53. Facility census: 104.

Inspectors wroteBased on record review and staff interview the facility failed to provide an environment for residents free from neglect and physical harm for one (1) of four (4). This failed practice caused physical harm to Resident #105. Resident #105 fell out of bed and injured his left arm. The failed practice was determined by the state survey team to have been corrected prior to entrance and will be cited at past non-compliance. Resident identifier: #105. Facility census: 104.

Inspectors wroteBased on water temperature measurement and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The hot water temperature in the hand washing sink located in the main dining room was at an unsafe temperature for resident use. The water temperature in the hand sink in the main dining room was tested with facility equipment by the facility's maintenance director at approximately 2:30 PM on 04/16/25 the temperature was 139.2 degrees Fahrenheit. The water temperature in the sink in the main dining room at 2:56 PM was obtained in the same manner mentioned above and was 125 degrees Fahrenheit. The state agency (SA) felt this put any resident who was able to wash their hands in this sink at an immediate risk for serious injury and/or death and created an Immediate Jeopardy (IJ) situation. [...]

Inspectors wroteBased on observation, record review, and staff review, the facility failed to ensure Resident #111 received respiratory care to ensure Resident #111's airway remained intact and was able to be reestablished immediately if the tracheotomy tube would become dislodged. This was true for one (1) resident reviewed for the care area of Respiratory care during the long term care survey process. The facility failed to ensure they had the supplies at bedside to replace Resident #111's tracheotomy canula. The physician orders and Resident #111's care plan dictated the supplies were to be kept at bedside. When the staff was asked were the supplies were to replace the canula were located, it took greater than 15 minutes to find the needed supplies in the supply closet. They were not kept at bedside as directed in the physician order and care plan. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure orders and interventions were followed to control pain for Residents #42 and #87. This was true for two (2) of six (6) residents reviewed for pain management during the survey process. Resident identifiers: #42, #87. Facility census: 111. The State Agency (SA) determined physical harm was caused to Resident #42 when the facility failed to check on, and assess, Resident #42 for pain, for approximately 50 minutes, despite him yelling out the entire duration, until surveyor intervention. At which time, it was discovered by Licensed Practical Nurse (LPN) #36, Resident #42 was in pain and requested pain medication. [...]

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to deploy sufficient direct care staff to meet the needs of the resident population of the facility. This had the potential to affect all residents residing in the facility. Resident identifiers: #94, #58, #51, #85, #91, and #84. Facility census: 111.

Inspectors wroteBased on record review, staff interview and resident interview, the facility failed to ensure the residents' right to to receive mail on Saturdays was honored. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 111.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow administration directions for medications prescribed for the control of phosphorous levels for dialysis patients. This was true for 5 of 5 residents on dialysis. Resident Identifiers: Residents #33, #88, #94, #105 and #108. Facility census:111. Findings Include: a) Resident #33 Record review and interview on 04/13/25 at 2:35 PM revealed, Resident #33 is a [AGE] year-old female on hemodialysis diagnosed with the following conditions: [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure each resident received the proper portion size of pork during the evening meal on 04/16/25. This failed practice has the potential to affect more than an isolated number of residents and was random opportunity for discovery found during the completion of the kitchen pathway during the long-term care survey process. Facility Census: 111. Findings Include: On 04/16/25 at 5:32 PM the surveyor was observing meal service from the steam table in the facility's kitchen. [NAME] #130 was serving the food from the steam table. She was observed using tongs to serve the pork. The Director of Operations (DOO) was asked how she was sure the pork she was serving was two ounces (OZ) she stated she should be using a 2 oz scoop and not tongs. She corrected the situation; [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure all residents received meals at regular times comparable to normal mealtimes in the community. The lunch meal on 06/04/25 was served 45 minutes late to 19 residents due to the facility running out of prepared food. This was true for Resident #95, #3, #68, #60, #90, #21, #29, #24, #56, #6, #61, #5, #41, #79, #38, #58, #36, #45, and #49. Facility Census: 101 Findings Include: a) An observation of the lunch meal began at 12:00 PM on 06/04/25 found the facility was serving ham, macaroni and cheese and beets as the main meal for the residents. At 1:10 PM [NAME] #1 stated, I ran out of food. I'm going to have to make more. The Corporate Director of Operations then began preparing and directing the staff on what to make to continue to the feed the remaining 18 residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control procedures were adhered to in the residents' shower room. This failed practice had the potential for infection of a limited number of residents. This was true for one (1) of two (2) shower rooms inspected during the survey process. Facility Census: 111.

Inspectors wroteBased on observation and resident interview, the facility failed to ensure Resident #94 was treated in a dignified manner, by allowing him to sit in a soiled brief for an extended period of time. This was a random opportunity for discovery. Resident Identifier: 94. Facility census: 111.

Inspectors wroteBased on record review and resident interview, the facility failed to ensure the resident's right to voice a grievance to the facility without fear of reprisal for Resident #58. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident Identifier: #58. Facility Census: 111.

Inspectors wroteBased on observation, resident interview, staff interview and record review, the facility failed to ensure Resident #26 and Resident #70 were not neglected. Resident #70 asked for a snack for over 30 minutes she was eventually given a snack but it was the wrong consistency. The nurse aide then had to take it from her which upset the resident. The facility also failed to give Resident #26 his medication even though it was available in the pyxis machine. This was true for two (2) of seven (7) residents reviewed for the care area of abuse during the long term care survey. Resident Identifiers: #70 and #26. Facility Census: 111. Findings Included: a) Resident #26 An interview with Resident #26 on 04/13/25 at 2:44 PM found the Licensed Practical Nurse's (LPN) often let him run out of medication and he don't get it until it comes in from the pharmacy. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) for Resident #13 upon discharge from the facility. This was true for one (1) of thirty-eight (38) residents. This was a random opportunity for discovery and was true for Resident #13. Resident Identifier: #13. Facility Census : 111.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the care plan was implemented regarding pain management interventions for Resident #42, and regarding tracheostomy care for Resident #111. This was true for two (2) of 38 resident care plans reviewed during the survey process. Resident identifiers: #42, #111. Facility census: 111.

Inspectors wroteBased on observation, record review, residen interview, staff interview, and facility policy review, the facility failed to assist dependent residents with activities of daily living (ADL's) in accordance with the residents assessed needs for care. This was true for two (2) of five (5) residents reviewed for ADL care. Resident Identifiers: #416 and #85. Facility Census: 111. Findings Included: a) Resident #416 On 04/16/25 at 11:28 AM, a review of Resident #416's toileting / toileting hygiene documentation in November 2024 found: --Day shift- three (3) entries of 97- Not applicable in 30 days. --Evening shift- three (3) entries of 97- Not applicable in 30 days. --Night shift- 12 entries of 97- Not applicable in only 30 days. During an Interview on 04/16/25 at 12:08 PM the Director of Nursing (DON) verified there was no documentation that Resident #416 received Toileting hygiene as needed. [...]

Inspectors wroteBased on record review, observation, staff interview and resident interview, the facility failed to follow a physician's order for no straws for Resident #10 and failed to ensure Resident #26 received medication as ordered. These failed practices had the potential to affect more than a limited number of residents. Resident Identifiers: #10 and #26. Facility Census: 111.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a newly admitted resident's indwelling catheter, and failed to obtain a physician's order for the care and maintenance of the catheter. In addition, the facility failed to provide the appropriate catheter care to prevent potential Catheter Associated Urinary Tract Infections (CAUTI's). This was true for one (1) of five (5) residents reviewed for catheter care. Resident Identifier: #266. Facility census: 111. Findings Included: a) Resident #266 During an interview on 04/13/25 at approximately 2:14 PM, Resident #266 stated she was looking forward to getting her catheter removed. Upon being asked if the facility provided catheter care, resident stated the staff usually emptied her catheter bag when it filled up. [...]

Inspectors wroteBased upon record review and staff interview, the facility failed to ensure resident received mental health referral and treatment. This was true for 1 (one) of 38 (thirty-eight) residents reviewed during this annual survey process. Resident identifier: #110. Facility census:

Inspectors wroteBased on record review and staff interview the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled to enable them to identify and correct any possible drug diversions. There were some discrepancies related to Resident #97's controlled substance log. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #97. Facility Census: 111. Findings Include: [...]

Inspectors wroteBased on record review, and interview, the facility failed to ensure the attending physician reviewed and acted on the Consulting Pharmacist's recommendations. In addition, the facility failed to ensure that the physician reviewed and documented a response to the recommendations. This was true for five (5) of five (5) residents surveyed. Resident Identifier: Resident #17, # 28, #53, #74 and #87. Facility Census: 111.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to ensure Resident #70's medication regimen was free from unnecessary antipsychotic medications. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the long-term care survey process. Resident identifiers: #70. Facility's Census: 111. Findings Include: a) Resident #70 On 04/14/25 at 9:05 PM the facility was entered on the night shift due to resident complaints of care on the night shift. Upon entrance to the facility Resident #70 was observed sitting in the doorway of the Cafe, the resident was yelling for help and asking for a snack. She later began asking for a specific snack of a peanut butter sandwich. Numerous staff were in the area and could have easily heard her asking for a snack. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to update orders to discontinue dialysis access care, and monitoring of the dialysis access graft/fistula. In addition, the facility failed to update orders and a care plan when a C-collar was discontinued. Resident Identifiers: #88, and #10. Facility Census: 111. Findings Include; a) Resident #88 During an interview, on 04/15/25 at approximately 1:20 PM, Resident #88 stated the dialysis access in her right upper arm was no longer patent. The resident stated he now had a dialysis catheter in her right upper chest, which was used during hemodialysis treatments. Record review on 04/15/25 at approximately 2:15 PM revealed the following order dated 10/08/24: External hemodialysis catheter 2 lumens (location) right chest wall with transparent dressing. DO NOT Change END caps. [...]

Inspectors wroteBased on staff interview and record review the facility failed to follow the diet order for a resident on a pureed diet. The wrong texture of diet was provided which resulted in a choking incident for Resident #112. This failed practice was found true for (1) of (3) residents reviewed for diet order accuracy during the survey process. Resident identifiers #112. Facility Census 111. The State Agency (SA) determined this placed the resident in a past non-compliance immediate Jeopardy (IJ) situation. Resident #112 was provided regular texture food, which caused her to choke. The resident late died. The SA called the past noncompliance IJ starting on 08/14/24 and ending on 08/22/24. The facility was notified of the IJ at 2:05 PM on 08/26/24. Findings Include: a) Resident #112 A record review on 08/26/24 at 12:05 PM, found Resident #112 was ordered the following diet: [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure bed rails were implemented within accepted standards of care. Three (3) of three (3) residents reviewed for the care area of bed rails did not have current orders for bed rails. One (1) of three (3) residents reviewed for the care area of bed rails did not have valid informed consent for bed rails. Resident identifiers: #12, #15, #96. Facility census: 111.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure foot care was provided to dependent residents. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of foot care. Resident identifier: #12. Facility census: 111.

Inspectors wroteBased on record review, staff interview and observation, the facility failed to provide adequate supervision to residents and to maintain an environment free of accident hazards. This failed practice was found true for (1) one of (1) one resident reviewed for accident hazards during the survey process. Resident identifier: #111. Facility Census 111. Finding Include: a) Resident #111 A review of the facilities reportables, on 08/29/24 at 8:45 AM, revealed a reportable dated 06/28/24 alleging Resident #11 was witnessed drinking from a bottle of wound cleanser which was left on the crash cart. A record review on 08/29/24 at 8:50 AM, revealed a general progress note date 06/28/24 which read as follows: Resident was witnessed drinking from a bottle of wound cleanser; another resident reported to nursing resident had consumed content from a bottle, staff immediately responded; [...]

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed for residents with Multidrug-resistant Organisms (MDRO's). Resident identifiers: #12, #17 and #72. Facility census: 110. On 07/18/24 at 3:51 PM an immediate jeopardy (IJ) was called at as this failed practice had the potential to affect all residents residing in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure four (4) residents were free of significant medication errors. On 07/11/24, the facility reported to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman that Resident #69, Resident #74, Resident #39, and Resident #108 were administered their 8:00 AM medications twice due to incomplete medication administration documentation. The facility developed and implemented a plan of correction on 07/11/24. The state agency investigated the matter on 07/18/24 and determined on 07/11/24 Resident #69, Resident #74, Resident #39, and Resident #108 were in an Immediate Jeopardy situation due to potential adverse consequences from duplicate medication administration. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician-ordered medication parameters were not followed. This deficient practice had the potential to affect (1) of four (4) residents reviewed during the investigation. Resident identifier: #39. Facility census: 110.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure services to meet professional standards of care. A medication labeled by the pharmacy to be used for a specific resident was used for another resident. This was a random opportunity for discovery found during medication administration observation. Resident identifiers: #4 and #52. Facility census: 110.

Inspectors wroteBased on staff interview and record review, the facility failed to provide a qualified activity professional for recreational services. This failed practice was a random opportunity for discovery and had the potential to affect all residents. Facility census: 110.

Inspectors wroteBased on facility policy review, record review and staff interviews, the facility failed to ensure resident to resident altercations were reported to all the proper State Agencies. This is true for four (4) of ten (10) incidents reviewed for resident to resident alterations. Resident Identifiers: Resident #83, Resident #92, Resident #79, Resident #40, Resident #95, Resident #11 and Resident #54. Facility Census: 110. Findings Included: A review of a facility policy titled OPS300 Abuse Prohibition: with a revision date of 10/24/22 read as follows. .Process: .7.4 Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source) suspected criminal activity, and misappropriation of patient property within 24 hours if the event does not result in serious bodily injury. .9. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one (1) of four (4) residents reviewed, who were unable to carry out activities of daily living, received services to maintain personal hygiene. Resident Identifiers: Resident #105. Facility census: 110.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician-ordered medication parameters were not followed for one (1) of three (3) residents reviewed receiving antihypertensive medications. Resident identifier: #105. Facility census: 110.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide nutritional adequacy by providing inconsistent portions of the food to maintain perimeters of health. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen. Facility census: 110.

Inspectors wroteBased on record review, observation, staff, and resident interview, the facility failed to ensure Resident #6 was provided with the appropriate supplemental oxygen. This failed practice was true for one (1) of three (3) residents reviewed for oxygen therapy. Resident identifier: #6. Facility census: 118.