Cedars Nursing Care Center

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 Wings ([NAME], Black Wolf and [NAME]) and the common area/hallway for 3 of 3 days of survey.

Inspectors wroteBased on performance evaluation reviews and interviews, the facility failed to complete annual performance evaluations at least every 12 months for 5 of 5 sampled employees. (Certified Nursing Assistant (CNA) #2, #3, #4, #5, and #6)

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to demonstrate staff competency for Infection Control in the areas of Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) in 3 out of 3 units surveyed for Infection Control and Prevention. ([NAME] Unit, Black/Wolf Unit, and [NAME] Unit).

Inspectors wroteBased on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to ensure that the CNA attended the mandatory yearly Resident Rights training for 5 of 5 CNA's reviewed. Furthermore, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training for 2 of 5 randomly selected CNAs employed greater than 1 year. (CNA #2, #3, #4, #5, #6)

Inspectors wroteBased on observations and interviews, the facility failed to promote care for residents in a manner that maintained the residents' dignity when staff failed to groom a resident on 1 of 3 days of survey (6/23/25) (Resident #34).

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 4 sampled residents reviewed for new admissions (Resident #281).

Inspectors wroteBased on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident for 1 of 25 reviewed for care planning. (Resident #65) On 6/23/25 at 9:26 a.m., during an interview, Resident #65 stated he/she has never heard of care plan meetings. Review of Resident #65's IDT care plan meeting notes showed IDTs occurring on 10/25/24, 1/28/25, 4/24/25, and 5/8/25. The medical record lacked evidence that he/she was invited and/or participated in his/her IDT meetings. On 6/25/25 at 1:00 p.m., the above was discussed with the Director of Nursing.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 2 of 2 kitchen observations, and in 1 of 3 Kitchenette observations.

Inspectors wroteBased on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 3 of 3 residential units.

Inspectors wroteBased on observation, record review and interview, the facility failed to revise the care plan to reflect a resident's current status for 1 of 3 residents reviewed for skin conditions (#21) and 1 of 1 resident reviewed for limited range of motion (#8).

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that nursing obtained new orders for wound care and followed physician orders for 2 of 3 residents reviewed for skin conditions (Resident #21 [R21], R30) and the facility failed to follow physician orders to obtain a urine sample for 1 of 2 residents reviewed for falls (R3).

Inspectors wroteBased on record review, observations and interviews, facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use on 3 of 3 neighborhoods observed ([NAME], [NAME], Black Wolf).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner due to the Dietitian walking through the kitchen with hair not contained or covered. Additionally, the walk-in refrigerator contained a pan of green beans that was not labeled or dated.

Inspectors wroteBased on record review, observations and interview, the facility failed to implement a care plan in the area of nutrition for 1 of 1 sampled resident for tube feedings (#36).

Inspectors wroteBased in record review, observation and interview, the facility failed to provide appropriate treatment to prevent the risk of complications related to enteral feeding, for 1 of 1 resident reviewed for tube feeding. (#36)

Inspectors wroteBased on observations and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to nebulizer and oxygen tubing for 2 of 2 residents reviewed for respiratory care. (#4, #82) Findings 1. On 4/1/24 at 9:48 a.m., Observation of Resident #21 to have a nebulizer pipe with tubing stored in a basin along with an exercise band and socks. At this time, during an interview, resident stated he/she has not used a nebulizer for, long time ago, only when I need it. On 4/2/24 at 2:29 p.m., both the Registered Nurse (RN#1) and surveyor observed the nebulizer pipe and tubing in the basin, the RN#1 removed/discarded the nebulizer pipe into the trash. [...]

Inspectors wroteBased on record review and interview, the facility failed to conduct an annual review of it's Infection Prevention and Control Program (IPCP).

Inspectors wroteBased on record reviews and interview, the facility failed to ensure 1 of 5 residents (#51) reviewed for immunizations was reviewed and offered pneumococcal vaccination in accordance with the United States Centers for Disease Control and Prevention (CDC) recommendations.

Inspectors wroteBased on record review, facility policy review, and interview, the facility failed to ensure that a resident was free from an avoidable accident hazard by not removing a hot pack timely for 1of 1 residents reviewed for accidents (#1).

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain an Infection Control Program designed to help prevent the development of infection related to personal equipment storage for 3 of 3 days of survey. In addition, the facility failed to assess and have measures in place to monitor and prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems.

Inspectors wroteBased on observations and interviews, the facility failed to store frozen foods in a safe and sanitary manner on 2 of 3 days of kitchen observations, and, failed to monitor chemical sanitizer levels for sanitizing buckets used to clean kitchen work areas. This has the potential to affect all residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure an as needed (PRN) antipsychotic medication order met the required 14-day time limit or provided the rationale to extend the time limit beyond the 14 days, with the indicated duration, for 1 of 5 residents reviewed for unnecessary medications (#31).

Inspectors wroteBased on observation and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 2 medication rooms and 1 of 4 medication carts observed (Black Wolf House).