Cedars Healthcare Center

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and dishroom. Specifically, the facility failed to ensure:-Staff used proper hand hygiene during meal service;-Food was held at the correct temperature;-Kitchen was maintained, in good repair to be able to have a cleanable surface.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide care to each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 12 (#2, #8, #13, #35, #37, #50, #69, #74, #92, #33 #44, #43, #93, #103 and #57) out of 55 sample residents. Specifically, the facility failed to respond to call lights in a timely manner for Resident #2, Resident #8, Resident #13, Resident #35, Resident#37, Resident #50, Resident #69, Resident #74, Resident #92, Resident #33, Resident #44, Resident #43, Resident #93, Resident #103 and Resident #57.

Inspectors wroteBased on interviews, and record review the facility failed to ensure prompt efforts by the facility to resolve grievances the resident may have for one (#33) of two out of 55 sample residents Specifically, the facility failed to make prompt efforts to resolve Resident #33's grievances.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of physical abuse to the State Survey and Certification Agency in accordance with state law for three (#56, #79 and #74) of six residents reviewed for abuse out of 55 sample residents. Specifically, the facility failed to:-Ensure an incident of alleged verbal abuse for Resident #56 was reported to the State Survey Agency;-Ensure an incident of alleged sexual abuse for Resident #79 was reported to the State Survey Agency; and,-Ensure an incident of alleged injury of unknown origin for Resident #74 was reported in a timely manner to the State Survey Agency.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of two medication carts and two of two medication rooms. Specifically, the facility failed to ensure:-Residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened; and, -Loose medications were not in the medication carts.

Inspectors wroteBased on observation and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infections. Specifically the facility failed to:-Ensure proper infection control practices, including enhanced barrier precautions, were followed during wound care;-Ensure proper hand hygiene during medication administration; and,-Ensure dwell times were followed during the disinfection process of the vital sign tower and resident glucometer.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to ensure resident complaints expressed during the resident council meetings were documented on a grievance and resolved to the residents satisfaction.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#56) of six residents were free from abuse out of 55 sample residents. Specifically, the facility failed to:-Protect Resident #56 from verbal abuse by licensed practical nurse (LPN) #8; and,-Removed LPN #8 from Resident #56's care following the incident of verbal abuse.

Inspectors wroteBased on record review, interviews, and observations, the facility failed to ensure two (#13 and #79) of two residents out of 55 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to:-Administer the correct dose of medication and accurately chart administration times for Resident #13; and, -Ensure Resident #79's medications were available for administration.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#8) of four residents received treatment and care in accordance with professional standards of practice out of 55 sample residents. Specifically, the facility failed to obtain physician's orders for Resident #8's wound in a timely manner.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#7) of two residents reviewed for ancillary services of 55 sample residents. Specifically, the facility failed to ensure Resident #7 received follow-up from the audiologist.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for two (#55 and #93) of seven residents reviewed for accident hazards out of 55 sample residents. Specifically, the facility failed to:-Ensure Resident #55 was not vaping in the dining room near other residents wearing oxygen; and, -Implement a smoking care plan to ensure safe smoking habits for Resident #93.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#53, and #70) of four residents who required respiratory care received care consistent with professional standards of practice out of 55 total sample residents. Specifically, the facility failed to:-Ensure Resident #53 and Resident #70's oxygen flow rate was set per physician`s order; and,-Ensure Resident #70's oxygen concentrator was functioning.

Inspectors wroteBased on observations, record review and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice, resident-centered care plans and resident's goals preferences for one (#2) of two residents reviewed for pain out of 55 sample residentsSpecifically, the facility failed to:-Complete a thorough assessment of the residents pain, including the site and pain goals; and,-Include person-centered non pharmacological pain interventions on the resident's care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#7) of two residents reviewed for ancillary services out of 55 sample residents received dental services timely. Specifically, the facility failed to ensure Resident #7 was provided with assistance to obtain replacement dentures.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure one (#7) of six residents reviewed for quality of care out of seven sample residents, received treatment and care in accordance with professional standards of practice. IMMEDIATE JEOPARDYResident #7 was admitted on [DATE] with diagnoses of Parkinson's disease (a progressive disease that causes symptoms such as tremors, stiffness and slow movement), epilepsy without status epilepticus (seizure lasting longer than five minutes, or two or more seizures without the resident gaining consciousness in between them), chronic respiratory failure, dependence on supplemental oxygen and cognitive communication deficit. On 6/26/25, Resident #7 experienced seizure activity that lasted longer than 30 minutes. During the seizure activity, the resident was observed to be having seizures by several staff members. [...]

Inspectors wroteBased on record review and interviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for two (#1 and #2) of six residents out of seven sample residents. Specifically, the facility failed to accurately document the administration of scheduled medications for Resident #1 and Resident #2.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents out of five sample residents received treatment and care for optimal skin condition of a contracted hand, in accordance with professional standards of practice. Specifically, the facility did not provide adequate skin care to prevent skin breakdown in Resident #1's contracted hands and between the resident's fingers and the thumb.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of three units. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touch areas (call lights, door handles and handrails); -Ensure housekeeping staff were trained appropriately on housekeeping procedures; and, -Ensure surface disinfectant times were adhered to.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for two (#180 and #40) of six residents out of 34 sample residents. Specifically the facility failed to: -Ensure Resident #180 was evaluated on admission for use of a restraint; -Ensure a consent was signed for use of a restraint for Resident #180 and #40; -Ensure there was a physician's order for restraints for resident #180 and #4; and, -Ensure there was a quarterly wander risk evaluation completed for Resident #40.

Inspectors wroteBased on record review and interviews, the facility failed to conduct a preadmission screening resident review (PASRR) for individuals remaining in a facility 30 days past provisional admission approval for one (#56) of one resident reviewed for PASRR out of 34 sample residents. Specifically, the facility failed to submit a new PASRR level I once an automatically approved provisional admission from a hospital had expired for Resident #56 after she had resided in the facility for more than 30 days.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (#64) of three residents reviewed out of 34 sample residents. Specifically, the facility failed to ensure Resident #64, who was dependent on staff for bathing, received her scheduled showers.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#74) of two residents reviewed for catheters of 34 sample residents. Specifically, the facility failed to: -Obtain physician orders for catheter use for Resident #74; -Ensure Resident #74 had a clinical indication (diagnosis) for catheter use prior to administration; -Ensure Resident #74 had a person centered care plan to address all care needs related to the resident indwelling catheter; and, -Ensure Resident #74's catheter drainage bag was not touching the floor.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#56) of one resident out of 34 sample residents. Specifically, the facility failed to identify Resident #56's post-traumatic stress disorder (PTSD) and identify triggers which may retraumatize her.

Inspectors wroteBased on observation and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on one of two medication carts and one medication storage room of two medication storage rooms. Specifically the facility failed to: -Ensure insulin (medications used for glucose control) pens and vials were labeled with open dates; and, -Ensure expired or discontinued medications were removed from the medication room and medication cart.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents out of eight sample residents received treatment and care in accordance with professional standards of practice. The facility failed to identify and respond to Resident #1's non-pressure related skin condition resulting in the development of osteomyelitis (bone infection), hospitalization and amputation of his left great toe. Resident #1, diagnosed with heart disease with heart failure and type 2 diabetes mellitus, was admitted to the facility 12/14/21. The facility failed to follow standards of practice in identifying, documenting, reporting to physicians and providing treatment per physician orders. The facility responded by educating nursing staff on the appropriate protocol for wound identification, management, condition changes and notification to appropriate parties. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) receives the necessary services and assistance with mobility for one (#4) of three out of eight sample residents. Specifically, the failed to provide necessary care and services to ensure for mobility consistent Resident #4's needs and choices.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#1, #2, #3, #5 and #8) of eight residents reviewed for immunizations out of eight sample residents. Specifically, the facility failed to: -Administer the pneumococcal vaccine after consent signed for Resident #2 and #5; and, -Offer the pneumococcal vaccination to Resident #1, #3 and #8 yearly after a refusal.

Inspectors wroteBased on observations and interviews, the facility failed to provide a comfortable and homelike environment on one out of three units. Specifically, the facility failed to ensure resident rooms were kept clean and residents had their belongings unpacked during a facility renovation.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for three (#48, #45 and #5) of three residents out of 42 sample residents. Specifically, the facility failed to: -Ensure there was a system in place to identify residents in need of one-to-one activities and developed a comprehensive care plan which addressed Resident #48, #45, #5's socialization and activity needs; and, -Provide the residents with a one-to-one activities plan.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure one resident (#177) was free from significant medication errors out of 42 sample residents. Specifically, the facility failed to ensure the resident was administered her morning medications before she left at 7:00 a.m. for a scheduled blood infusion at a hospital.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in two out of three units. Specifically, the facility failed to: -Ensure resident rooms were cleaned in a sanitary manner; -Ensure hand hygiene was performed in between gloves changes and that gloves were changed throughout the cleaning process of resident rooms; -Ensure manufacturer recommended surface contact times were followed for effective disinfection; and, -Ensure oxygen tubing and nasal cannulas were stored off the floor, in a clean bag and replaced when contaminated.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#45) of one resident out of 42 sample residents had the right to participate in the development and implementation of her person-centered plan of care. Specifically, the facility failed to conduct consistent care plan meetings for Resident #45 and ensure either the resident or the responsible party was involved in the conferences.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure two (#40 and #32) of four residents remained free from resident-to-resident abuse, out of 42 sample residents. Specifically, the facility failed to: -Prevent resident-to-resident physical abuse between Residents #40 and #74; and, -Prevent resident-to-resident physical abuse between Residents #18 and #32.

Inspectors wroteBasedonobservations recordreviewandinterviewsthefacilityfailedtoensurethatactivitiesofdailyliving(ADL fordependentresidentswereprovidedforthree(#42, #14 and#65) oftenoutof42 sampleresidents Specifically thefacilityfailedto -EnsurethatResident#42 and#14, whowereatriskforskinbreakdown wererepositionedtimely and -Resident#65 wasofferedandprovidedshowers

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the residents environment was free from accident hazards and received supervision and assistance to prevent accidents and hazards for one (#37) out of 42 sample residents. Specifically, the facility failed to ensure that Resident #37 did not keep medications at the bedside.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide person centered interventions for one (#28) resident, who was diagnosed with dementia, to maintain her highest physical, mental and psychosocial well being out of 42 sample residents. Specifically, the facility failed to ensure that effective person centered interventions for Resident #28 with a dementia diagnosis and who wandered.