Cedars Health Center

Inspectors wroteBased on observation, resident, staff, and family interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for personal hygiene and grooming for five (5) of 28 sampled residents. Resident #4, #10, #34, #60, and #92 Findings Include: Review of the facility policy titled Comprehensive Care Plans unrevised, revealed under, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan Resident #4 Record review of Resident #4's Care Plan Report revealed that he needed assistance with ADL's (Activities of Daily Living) related to recent hospitalization for left femur fracture, total hip arthroplasty d/t autoimmune encephalitis, falls, episodes of confusion. He has weakness and requires staff assistance with dressing, bathing, personal hygiene and transfers, w/c for mobility. [...]

Inspectors wroteBased on observation, staff, resident, and resident representative interview, record review, and facility policy review, the facility failed to provide nail care (Resident#10 and Resident #92), and shaving (Resident#4, Resident #34, Resident #60 and Resident #92) for five (5) of 28 sampled residents. Resident #4, #10, #34, #60, and #92Findings Include: Review of the facility policy titled Activities of Daily Living unrevised, revealed under, Policy Explanation and Compliance Guidelines: . 2. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #4 During an observation on 11/17/25 at 11:00 AM it was revealed that Resident #4 was lying in bed unshaved. His facial hair was approximately one-eighth (1/8) inch long and gray. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain a wheelchair in a clean and sanitary manner for one (1) of seven (7) residents using mobility devices in house 600. Resident #92 Findings Include: Review of the facility policy titled Safe and Homelike Environment unrevised, revealed under, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. An observation of Resident #92 on 11/17/25 at 11:35 AM revealed she was sitting in her wheelchair in the front lobby area. The lower wheelchair frame and left wheel were covered in an orange-colored dried substance. An observation and interview with Certified Nurse Aide (CNA) #6 on 11/18/25 at 1:15 PM confirmed Resident #92's wheelchair was dirty and covered in a dried substance that she thought was food. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to monitor refrigerated medications for proper temperature control to ensure safe medication storage for one (1) of 11 medication refrigerators in facility.

Inspectors wroteBased on facility policy review, record review and interviews, the facility failed to ensure a resident's right to be free from neglect for one (1) of four (4) sampled residents, Resident #1. On 10/14/25 at approximately 10:16 AM, after returning to the facility from an appointment the facility abandoned Resident #1 on the facility's transport van. Resident #1 was left alone and unattended on the facility transport van for approximately two hours. At 12:15 PM, the facility staff located Resident #1 still strapped in the facility transport van. This resulted in Resident #1 missing her hydration, care and expressing a fear that she was anxious, and thought she would die. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) at Past Non-Compliance (PNC). [...]

Inspectors wroteBased on staff, and resident, caregiver, and responsible party interviews, record review, and facility policy review the facility failed to accurately complete an elopement assessment and identify risks to prevent an unsupervised resident from exiting the facility door for one (1) of three (3) residents reviewed for elopement and wandering. Resident #1. Findings Include: Review of the facility policy, Accidents and Interventions dated 05/05/19 revealed, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s) . An interview on 05/05/25 at 8:45 AM with Administrator (ADM), revealed that on 04/26/25, they had a resident to propel himself in his wheelchair outside the facility through an automated sliding door. [...]

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review, the facility failed to ensure a resident's wheelchair was in good repair for one (1) of 26 residents reviewed during survey. Resident #236 Findings Include: Review of facility policy titled, Safe and Homelike Environment date implemented 1/2024, revealed under the Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belonging to the extent possible. This includes ensuring the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk . [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to accurately submit information into the Minimum Data Set (MDS) assessment system for one (1) of 26 residents sampled.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for a resident that required the use of Enhanced Barrier Precautions (EBP) (Resident #85) and assistance with Activities of Daily Living (ADL's) (Resident #106) for two (2) of twenty-six care plans reviewed. Resident #85 and #106 Findings Include: Record review of the facility policy titled Comprehensive Care Plans dated 10/2022 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #85 Record review of Resident #85's Care Plan revealed Focus: [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide the necessary assistance with activities of daily living (ADLs) for a resident dependent on staff for bathing, shaving, and nail care for one (1) of 26 residents sampled. Resident #106 Findings Include: Record review of the facility policy titled Activities of Daily Living dated 10/2023 revealed Policy . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . An observation of Resident #106 on 8/5/2024 at 12:09 PM revealed, he was lying in bed, alert with confusion. The resident was unkept, with his hair unbrushed and greasy on the edges. Gray facial hair was observed on his face and above his lip, measuring approximately one fourth (1/4) inch in length. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than five (5) % (percent) for two (2) of 28 medication opportunities involving Resident #84. Medication error rate was 7.14%. Findings Include: Review of the facility policy titled Medication Administration dated 1/2024 revealed Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines: 10. Ensure that the six rights of medication administration are followed .c. Right dosage . [...]

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review the facility failed to prevent the possibility of the spread of infection as evidenced by failing to ensure Enhanced Barrier Precautions were followed during a resident care treatment for one (1) of four (4) resident care treatments observed. Resident #85. Findings Included: Record review of the facility policy Gastrostomy Site Care dated 05/2023 revealed Policy: It is the policy of the facility to perform gastrostomy site care as ordered and per current standard of practice. Policy Explanation and Compliance Guidelines .10. Apply any other PPE (Personal Protective Equipment) as needed to protect self from any exposure to infectious material and to comply with any isolation precautions ordered . [...]

Inspectors wroteBased on staff interviews, Resident Representative (RR) interview, record review and facility policy review, the facility failed to ensure that one (1) of five (5) sampled residents were protected from physical abuse. Resident #1.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review the facility failed to promote and maintain the dignity of a resident as evidenced by a urinary catheter bag with no privacy bag for one (1) of four (4) residents reviewed with a urinary catheter. Resident #115 Findings Include: Record review of the facility policy titled, Promoting/Maintaining Resident Dignity with a revision date of 10/2022 revealed Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality 12. Maintain resident privacy . [...]

Inspectors wroteBased on observation, staff and resident interview, and record review the facility failed to provide a resident with an appropriately sized wheelchair for one (1) of 32 residents reviewed.

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to ensure that a Certified Nurse Assistant (CNA) maintained an up-to-date certification for one (1) of 115 certifications reviewed.

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to change gloves during wound care while going from a dirty site to a clean site and failed to perform hand hygiene between glove changes for one (1) of four (4) residents observed during wound care.