Cedars Healthcare Center

Inspectors wroteBased on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of practice with regards to medication administration for three residents (Resident #2- R2, Resident #4-R4, and Resident #5 -R5), in a survey sample of six residents.

Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for one resident (Resident #2- R2) in the survey sample of six residents.

Inspectors wroteBased on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure medications were available for administration for four residents (Resident #4-R4, Resident #5-R5, Resident #1-R1, and Resident #20-R20) in a survey sample of 6 residents.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare and serve food in a sanitary manner in the main kitchen, having the potential to affect multiple residents on 4 of 4 nursing units.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to implement their abuse policy with regards to the pre-screening of employees for 24 employees in a survey sample of 26 employee records reviewed.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to follow physician orders for seven of thirty residents in the survey sample (Residents #20, #40, #70, #77, #80, #93 and #323).

Inspectors wroteBased on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure medications were available for administration for six residents (Resident #80-R80, Resident #69-R69, Resident #70-R70, Resident #20-R20, Resident #40-R40, and Resident #93-R93) in a survey sample of 30 residents. The facility staff also failed to ensure medications were available during medication administration on two units (200 unit and 400 unit) out of four units.

Inspectors wroteBased on observation, staff interview and facility document review, the facility failed to properly store medications on two of four units (200-unit, 300-unit).

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve food in a sanitary manner in the main kitchen and in the dining room.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to educate about and offer pneumococcal immunizations according to the facility's infection control policy for three of five residents reviewed (Residents #20, #93, and #94). The pneumococcal immunization status was not documented and/or up to date in the clinical record for five of five residents reviewed (Residents #20, #53, #84, #93, and #94).

Inspectors wrote2. The facility staff failed to notify all required agencies of an allegation of abuse that involved R11 and certified nursing assistant, CNA#3. On 11/21/24 a review of facility documentation was conducted, which includent the incident summary and the facility synopsis of an allegation of abuse that involved R11 and CNA#3. No documentation was found that showed that the Virginia Department of Health professions (DHP) was notified of the determination of abuse that involved a certified nursing assistant, identified as CNA3. While the incident summary was completed on 9/15/24. the facility fax confirmation read, no answer, for the DHP on 9/16/24 and 9/19/24, On 11/21/24 at 2:00 p.m., an interview was conducted with the administrator. The Administrator said, Sometimes the fax numbers are busy, and we have to keep faxing. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide credible evidence of an investigation being conducted following an allegation of sexual abuse for one resident (Resident #120-R120) in a survey sample of 30 residents.

Inspectors wroteBased on staff interview and clinical record review, the facility failed to develop a care plan for one of thirty one residents. Resident #5 (R5) did not have a complete care plan developed for incontinence. The Findings Included Review of R5's clinical record noted diagnoses for R5 included incontinence of bowel and bladder, chronic congestive heart failure, and chronic atrial fibrillation. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 9/27/24, which assessed R5 with a cognitive score of 14 out of 15, indicating cognitively intact. On 11/19/24 at 11:41 a.m. during an interview, R5 verbalized having incontinent episodes and that the staff did a good job at keeping her clean and dry. Review of R5's MDS dated [DATE], Section H - Bowel and Bladder, documented that R5 was Always Incontinent of bowel and bladder. [...]

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide respiratory care for three residents, Resident #77 (R77), Resident #83 (R83), and Resident #5 (R5) out of a survey sample of 30 residents.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 percent. Medication pass observations resulted in two errors out of thirty opportunities for an error rate of 6.67%.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide routine dental services to two residents (Resident #80-R80 and Resident #4-R4) in a survey sample of 30 residents.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure a therapeutic diet and correctly provide foods per the meal ticket for one of thirty residents in the survey samplec, (Residents #103). Resident #103 (R103) was not provided foods per meal ticket for lunch.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to honor food preferences for one of thirty residents in the survey sample (Resident #93).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for one of thirty residents in the survey sample (Resident #94).

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to follow infection control practices during medication pass and pour observation on one of two units.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to educate about and offer COVID-19 immunizations according to the facility's infection control policy for two of five residents reviewed (Residents #20 and #94).

Inspectors wroteBased on observations, resident interview, staff interview, and facility document review, the facility staff failed to ensure oxygen concentrators were in proper working condition for one resident, Resident #77 (R77) out of a survey sample of 30 residents.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for one of nine residents in the survey sample, Resident #4.

Inspectors wroteBased on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide incontinence care for dependent residents for three of nine residents, Resident #3, Resident #6 and #7.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to maintain residents' highest level of well-being for two of nine residents in the survey sample, Residents #4 and #5.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for the treatment of pressure injuries for one of nine residents in the survey sample, Resident #4.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a safe environment by monitoring the wander guard for one of nine residents, Residents #9.

Inspectors wroteBased on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a safe environment for one of nine residents, Resident #3.

Inspectors wroteBased on review of facility's documentation and staff interview, it was determined that the facility failed to allow the resident to make decisions regarding her treatment for one of nine residents, Resident #2.

Inspectors wroteBased on observation, resident/staff interview, facility document review, and clinical record review, the facility staff failed to report an allegation of resident who was on the roof with potential for self-harm for 1 of 9 residents, Resident #3.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide treatment and services for one of nine resident's indwelling catheter, Residents #1.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility failed to ensure dignity and respect for one resident. Resident #1's (R1) personal belongs were removed and staff did not leave room after being asked. The Findings Include: Diagnoses for R1 included: Congestive heart failure, anxiety, depression, and chronic obstructive pulmonary disease. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 10/4/23. R1 was assessed with a cognitive score of 14 out of 15, indicating intact cognition. [...]

Inspectors wroteBased on resident council interview, staff interview and facility document review, the facility staff failed to response promptly to call bells on three of four nursing units (100-unit, 200-unit and 300-unit).

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide a registered nurse (RN) at least eight consecutive hours per day for four out of thirty days in September 2022.

Inspectors wroteBased on resident interview, staff interview, facility document review and during the course of a complaint investigation, the facility staff failed to ensure reasonable care and protection of resident property from loss and/or theft for one of 27 residents (Resident #10) regarding an iPad and a framed painting; and failed to ensure a safe homelike environment for one of 27 residents (Resident #21) regarding the resident's room, room equipment and room furnishings.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to review and revise a care plan for four of 27 residents in the survey sample, and failed to ensure residents were extended an invitation to the care plan meetings and active participation from the facility's required interdisciplinary team members for two of 27 residents in the survey sample. Resident #24, Resident #75, and Resident #21 care plans were not reviewed and revised regarding code status changes and Resident #35's care plan was not reviewed regarding medication changes. Resident #94 and Resident #12 were not extended invitations to the care plans meetings and facility's required interdisciplinary team members did not actively participate in the care plan meetings.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility failed to ensure glasses were ordered to maintain vision for two of 27 residents, Resident's #12 and #94. The Findings Include: 1. Resident #12 was admitted to the facility on [DATE]. Diagnoses for Resident #12 included: Congestive heart failure, kidney disease, anxiety, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 3/25/21. Resident #12 was assessed with a cognitive score of 15 indicating cognitively intact. Section B of the current MDS documented Resident #12's vision was adequate with corrective lenses. On 06/22/21 at 12:21 PM. Resident #12 was interviewed. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, the facility staff failed to ensure effective pest control in the facility for two resident rooms on the 400 unit (room [ROOM NUMBER] and 413), and in the hallway on the 400 unit, where gnats were observed; and failed to ensure effective pest control for flies and gnats observed in room [ROOM NUMBER] and 120 and 100 unit area.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to promote dignity and respect for one of 27 residents in the survey sample, Resident #43. Facility staff provided incontinence care and a bed linen change while the resident was verbally refusing the care.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide an accessible light switch for one of 27 residents in the survey sample, Resident #21. Resident #21's over-bed light was not equipped with a cord so the resident could turn the light on/off as desired.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete minimum data set (MDS) for two of 27 residents in the survey sample. MDS assessments for Resident #32 and #43 were incomplete with no indicators of cognitive status or mood.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to ensure necessary care and treatment to prevent infection during a dressing change for one of 27 residents (Resident #35).

Inspectors wroteBased on medication pass observation, staff interview, and clinical record review, the facility failed to ensure medications were available for one of 27 residents, Resident #61. Resident #61 did not have Lactulose solution (for treatment of constipation and liver disease) available to give during the morning medication pass.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to implement food preferences for two of 27 in the survey sample, Resident #109 and Resident #481.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care for two of 29 residents in the survey sample, Resident #105 and Resident #42. Resident #105 was administered another resident's medications in error. Nurses failed to clarify a physician's order prior to administration of a medication to Resident #42.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure physican's orders were in place for a hand splint for Resident # 1.

Inspectors wroteBased on observation, staff interview, and resident interview, the facility staff failed to implement care plan interventions for vision deficit for one of 29 residents, Resident #56; and failed to develop a care plan for a hand splint for one of 28 residents, Resident #1.

Inspectors wroteBased on observation, staff interview, resident interview, and facility document review, the facility staff failed to provide nail care for one of 29 residents, Resident #56.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to physician orders for three of 29 residents in the survey sample. Facilty staff failed to obtain vital signs every 4 hours after a medication error for Resident #105; failed to follow orders for medication administration for Resident #123, and failed to implement a bowel management program for Resident #76.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to follow physician's orders to float heels while in bed, for one of 29 residents in the survey sample, Resident #121. The Findings Include: Resident #121 was admitted to the facility on [DATE]. Diagnoses for Resident #121 included; Diabetes, dementia, Alzheimer's disease, and dysphagia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/10/19. Resident #121 was assessed with a score of 4 indicating severe cognitive impairment. On 7/30/19 Resident # 121's medical record was reviewed. An active physician's order dated 10/4/16 documented float heels when in bed to decrease pressure on heels. On 7/31/19 at 9:50 AM, Resident #121 was observed laying in bed. [...]

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure one of 29 residents in the survey sample was free of unnecessary medications. Resident # 71 in the survey sample had a PRN (as needed) order for Ativan for longer than 14 days without a stop date.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to label a medication accurately for one of 29 residents in the survey sample. Resident #42's medication Synthroid was labeled by the pharmacy with inaccurate dosage instructions.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure laboratory results were promptly reported to the physician for one of 29 residents (Resident #77).

Inspectors wroteBased on a medication pass and pour observation, staff interview and facility document review, the facility staff failed to ensure infection control practices were followed for medication administration.