Cedar Ridge Inn

Inspectors wroteBased on record review and interviews, the facility failed to ensure the environment was free of accident hazards for 1 (R #1) of 1 (R #1) resident, when the facility staff did not utilize safe resident handling techniques during a mechanical lift (a device designed to help staff move a resident from one place to another within a room or from one position to another) transfer. This deficient practice is likely to result in residents experiencing avoidable accidents and increases the risk of serious injury and harm.

Inspectors wroteBased on record review and interviews, the facility failed to provide quality care that meets professional standards for 1 (R #2) of 3 (R #2, #3, and #7) residents reviewed, when staff: Discontinued an eye drop medication without a physician's order and authorization. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider, and potential complications.

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (R #1) of 1 (R #1) resident reviewed, when: The facility did not provide continuous oxygen (O2) per physician's orders due to O2 equipment failure. If the facility fails to provide O2 per physician orders, then residents may receive substandard care and treatment, placing them at risk for preventable harm.

Inspectors wroteBased on interview and record review, the facility failed to prevent the worsening of a pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) for 1 (R #10) of 3 (R #10, #12 and #13) residents when staff failed to notify the physician when the resident's right gluteal fold (buttocks) wound worsened. If the facility does not recognize and notify the physician when a wound deteriorates, then the wound may worsen, become infected, and result in hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to secure an oxygen cylinder to prevent tipping and falling over for 1 (R #13) of 2 (R #13 and R #14) residents. If the oxygen container fell over, then the valve could break on the canister and cause the residual oxygen to leak or cause the oxygen cylinder to self-propel across the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain the kitchen in a sanitary manner for all residents who received food or drinks in the facility when staff failed to: - Keep the kitchen dust and grime free. - Ensure the ice machine drained through an air gap. These failures had the potential to result in cross-contamination and foodborne illness which could affect all residents who ate food from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment for all residents who utilized the outdoor patio located outside the main dining room when staff failed to repair water damage to the building. Failure to make repairs to maintain a homelike environment could likely cause residents to feel like they do not matter.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain an environment that was free of potential for accidents when staff failed to: - Use footpedals when they propelled residents in their wheelchairs without the foot pedals attached for 2 (R #26 and R #3) of 2 (R #26 and R #3) residents reviewed - Maintain a resident courtyard free of sharp edges. This failure had the potential to affect all resident who utilized the enclosed courtyard. These deficient practices could likely create an unsafe situation and lead to serious injuries.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met when staff failed to: -Promptly identify a loss of a controlled medication (drugs or chemicals that the government regulates because they can be easily abused and lead to addiction.) for 1 (R #26) of 1 (R #26) resident. -The Director of Nursing (DON) did not notify the facility's pharmacist consultant of the lost controlled medication timely. These deficient practices are likely to lead to a delay in the incident investigation process and lead to potential drug misuse or diversion (medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use).

Inspectors wroteBased on record review and interviews, the facility failed to provide a diet that met a resident's special dietary needs for 1 (R #249) of 1 (R #249) resident when staff failed to provide R #249 a salt free diet. This deficient practice is likely to lead to a buildup of fluid in R #249's body, causing him to have symptoms such as swelling in the legs, hands, and face, high blood pressure, shortness of breath, and potential complications like heart failure.

Inspectors wroteBased on interview and record review, the facility failed to properly care for a pressure ulcer (an injury that breaks the skin and underlying tissues) for 1 (R #195) of 6 (R #9, R #16, R #35, R #40, R #194, and R #195) residents randomly sampled for pressure ulcer, when they failed to do the following: 1. Monitor redness before it became a pressure wound. 2. Implement preventative interventions including pressure relieving devices 3. Delay in initiating wound care treatment for 11 days upon the discovery of (2) wounds. 4. Not consistently treating the wound with ointment as ordered. These deficient practices likely resulted in the development of unstageable wound with infection requiring hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to: 1. Ensure that opened insulin flex pen (pre-filed with insulin) were dated as to when they were opened by nursing staff. 2. Ensure expired supplies were not stored with unexpired supplies. 3. Document daily medication temperatures for refrigerator in medication room and medication carts, and medication room internal temperatures daily. These deficient practices could likely to result in all 89 residents that were identified on the census list provided by the Executive Director (ED) on [DATE] to receive expired or improperly temperature-controlled medications that have either lost their potency or effectiveness.

Inspectors wroteBased on observation and interview, the facility failed to serve food under sanitary conditions by: 1. Not dating food packages in kitchen refrigerators, freezers, and bulk dry goods bin; and 2. Not using proper handling techniques of drinks and bowls while distributing meals to residents in the dining room. These deficient practices are likely to affect all 89 residents listed on the resident census list provided by the Administrator on 11/27/23; and could likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This deficient practice has the potential to affect any of the 89 residents identified on the census provided by the Nursing Home Administrator (NHA) on 11/27/23, and who might be placed on antibiotics, which could result in the inappropriate use of antibiotics and that can lead to resistance of multi-drug resistant organisms.

Inspectors wroteBased on observation and interview the facility failed to treat residents with respect and dignity for 3 (R #9, R #14, and R #86) of 3 (R #9, R #14, and R #86) residents randomly identified when they failed to: 1. Ensure staff knock on the resident's bedroom door upon entering and 2. Ensure staff acknowledge residents upon entering their room and explain what service/care will be provided. These deficient practices could likely result in residents feeling unimportant and lack of having the privacy.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide accommodation of residents needs for 2 (R #5, and R #14) of 3 (R #5, R #14 and R #20) residents reviewed for call lights/ pressure pads within reach. This deficient practice is likely to result in residents being unable to request assistance, such as needing help with transferring, after falling, or other acute distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure grievance (complaints over something believed to be wrong or unfair) documentation included a summary of the investigation and findings or conclusions regarding the resident's concerns for 19 (R #4, R #5, R #8, R #11, R #13, R #18, R #21, R #24, R #26, R #34, R #35, R #40, R #46, R #50, R #56, R #63, R #65, R #66, and R #69) of 21 (R #3, R #4, R #5, R #8, R #11, R #13, R #18, R #21, R #24, R #26, R #34, R #35, R #37, R #40, R #46, R #50, R #56, R #63, R #65, R #66, and R #69) residents reviewed for grievances. This deficient practice could likely result in residents feeling unimportant and/or unsatisfied with the results of the grievance process.

Inspectors wroteBased upon observation, record review and interview, the facility failed to provide blood glucose monitoring (the use of a glucose meter for testing the concentration of glucose in the blood) for 2 (R #61 and R #200) of 2 (R #61 and R #200) residents and flushing a peripherally inserted central catheter line (PICC-a long, thin, flexible tube which is put into the arm to give chemotherapy and other treatments) for #61 by a qualified and trained nursing staff. This deficient practice could likely result in inaccurate glucose measurements, inaccurate treatments, and could lead to unnecessary accidents or injury.

Inspectors wroteBased on interview and record review the facility failed to maintain records of controlled substances (drugs that are subject to strict government control because they may cause addiction) on A, B and D medication cart. They failed to properly keep track of controlled substances kept in the medication carts. This deficient practice could cause the likelihood of a controlled substance being diverted (a medical/legal concept including the transfer of any illegal substance from the individual for whom it was prescribed a controlled substance from the individual for whom it was prescribed to another person for illicit use).

Inspectors wroteBased on record review and interview, the facility failed to ensure that medical records were complete and accurate for 3 (R #52, R #54 and R #83) of 4 (R #5. R #52, R #54 and R #83) residents reviewed for accuracy of documentation and written orders, and medication card matching the physcians orders. These deficient practices has the potential to negatively impact the continuum of care (continuum of care-a concept involving an integrated system of care that guides and tracks patient over time through a comprehensive array of health services spanning all levels of intensity of care), by staff misidentifying resident needs due to missing and inaccurate records.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain proper infection prevention measures by: 1. Ensuring staff members wear appropriate PPE (personal protective equipment) while sorting contaminated laundry in the laundry room. 2. Disinfecting the glucometer correctly for 2 (R #61 and R # 200) of 9 (R #3, R #23, R #36, R # 42, R #61, R # 80, R #193, R #198 and R #200). 3. Not storing staff belongings in the medication cart. 4. Ensure safe transport of soiled laundry from resident rooms to the laundry room. Failure to adhere to an infection control program could likely cause the spread of infections and illness to all 89 residents listed on the census provided by the Nursing Home Administrator (NHA) on 11/27/23.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician that Vancomycin (antibiotic medication used to treat serious, life-threatening infections by gram-positive bacteria that are resistant to less-toxic agents) trough level (measure of concentration of medication in the blood prior to the next dose to monitor for toxicity) was not checked prior to administering the next dose of the antibiotic for 1 (R #194) of 1 (R #194) resident. This deficient practice could likely cause toxic levels of Vancomycin to build up in the body of the resident leading to harm or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure lab work (a process of collecting blood samples to determine therapeutic levels of medication is the body) was completed as ordered by the physician for 1 (R #194) of 1 (R # 194) residents randomly sampled. This deficient practice of not obtaining lab work could result in health concerns not being addressed timely and can cause health problems such as a Vancomycin Trough level (Peak and trough levels are usually monitored, Toxicity is best monitored by looking at lab values) toxicity to go unidentified.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure a sanitary (clean) environment by allowing air pressure in the clean linen holding area of the laundry rooms to be negative [pressure inside an environment is less than the pressure of its surroundings resulting in a vacuum effect causing the air to flow in from the outside] to the adjacent [next to] hall. This deficient practice may likely result in decreased air quality in the clean laundry folding and holding area and contamination of the clean linen in the laundry area by any dust or dirt with contaminant particles [polluting/impure] in the hall.

Inspectors wroteBased on record review and interview, the facility failed to maintain a process of establishing an updated and valid advanced directive (a written statement of a person's wishes regarding their desire to receive medical treatment for prolongment of life or not) for 5 (R #'s 40, 69, 70, 76, & 234) of 5 (R #'s 40, 69, 70, 76, & 234) residents reviewed for advanced directives. This deficient practice could likely result in a resident not having their preferences honored during a life or death situation by not having the physician sign the form.

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing program of activities designed to meet the interests of residents and promotes well being for 2 (R #2 and 36) of 2 (R #2 and 36) residents reviewed for activities by, not identifying residents interests and providing meaningful individualized activities for the residents affected. This deficient practice could likely cause residents to experience boredom, feelings of isolation (the condition of being alone, especially when this makes you feel unhappy) and/or depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) by not enhancing their social and emotional well-being.

Inspectors wroteBased on observation, interview, and record review,the facility failed to: 1. Maintain a process that would ensure that oxygen tubing was dated when changed for 5 (R#'s 59, 60, 70, 132 and 183) of 5 (R#'s 59, 60, 70, 132, and 183) residents reviewed for oxygen care and 2. Ensure humidifier bottles was labeled for 1 (R #60) of 1 (R #60) reviewed for oxygen care. These deficient practices could likely lead to confusion amongst the staff as to when the oxygen tubing and humidifier bottles are due to be changed to prevent infection as a result of unsanitary (dirty or unhealthy and therefore likely to cause disease) conditions.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed 5 percent by performing 2 medication errors out of 30 opportunities for error, resulting in an error rate of 6.67 percent. Medication errors were observed for 2 (R # 182 and 233) of 7 (R #'s 10, 16, 29, 55, 64, 182 and 233) residents by: 1. Failure to aspirate [pull back on] a peripherally inserted central catheter (PICC-a long IV that goes into a large vein by the heart) line to ensure it is in a vein, prior to flushing [pushing into with an ordered intravenous (IV) fluid] for R #182 and 2. Administration of the medication Tamsulosin [is used by men to treat the symptoms of an enlarged prostate {part of the male reproductive system that is located just below the bladder}] to R #233, which had been discontinued on 09/02/22. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all insulin [medication that regulates the body's use of food] was properly labeled for individual resident use. This deficient practice puts any resident receiving insulin from those vials at risk for being injected with a contaminated/possibly toxic dose of insulin.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide assistive devices for 1 (R #45) of 1 (R #45) residents reviewed during dining observation for adapted eating utensils. This deficient practice could likely result in residents being unable to consume their meals resulting in weight loss.