Cedarvale Commons Rehabilitation and Healthcare Ce

Inspectors wroteBased on staff interview, record review, and review of facility policy, the facility failed to transfer a resident as per the care plan resulting in a fall. This affected one (#54) of three residents reviewed for accidents. The facility census was 87 residents.

Inspectors wroteBased on personnel record review, staff interview, and review of facility policy and procedure, the facility failed to ensure Certified Nurse Aides (CNA) had annual performance evaluations. This had the potential to affect all facility residents. The facility census was 64.

Inspectors wroteBased on observation, resident interview, staff interview, review of dietary production spreadsheets, review of resident meal tickets, and review of the facility's always available menu, the facility failed to ensure portion sizes were served as planned, which had the potential to affect all residents. The facility also failed to ensure items on the always available menu were available for Resident #17 and Resident #37. This affected two residents (#17 and #37) out of 64 residents observed during dining. The facility also failed to ensure the meal served matched the meal ticket. This affected two Residents (#10 and #21) of three observed for meal tickets. The facility census was 64.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure staff wore hair nets in the kitchen as appropriate. This had the potential to affect all 64 residents in the facility.

Inspectors wroteBased on personnel record review and staff interview, the facility failed to ensure nurse aides completed 12 hours of annual in-services. This had the potential to affect all facility residents. The facility census was 64.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed in a timely manner. This affected four residents (#17, #47, #54, and #60) of four residents reviewed for timely MDS completion.

Inspectors wroteBased on medical record review, staff interview, resident interview, and policy review, the facility failed to ensure care plans were updated/revised as needed and accurate. This affected four (#4, #10, #21, and #55) of 22 residents reviewed for care planning. The facility also failed to ensure care conferences were held on a routine basis. This affected three (#10, #50 and #162) of four residents reviewed for care conferences.

Inspectors wroteBased on observations, record reviews, staff interview, and review of facility policy and procedure, the facility failed to ensure fall investigations were completed thoroughly, included a root cause analysis, and appropriate fall interventions were initiated and in place. This affected four residents (#21, #25, #38, and #162) of five reviewed for falls. The facility census was 64.

Inspectors wrote3. a. Review of the record for Resident #59 revealed an admission date 10/05/23. Diagnoses included type two diabetes and developmental disorder of scholastic skills. Review of Resident #59's physician order dated 12/09/24 revealed that Resident #59 had an order for Insulin Lispro injection solution 100 unit per milliliter subcutaneously before meals and at bedtime for diabetes. Review of the plan of care dated 04/03/25 revealed that Resident #59 had impaired metabolic status related to diabetes. Interventions included administering medication as ordered, monitoring laboratory results, monitoring vital signs, and reporting adverse side effects to the physician. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #59 had Brief Interview for Mental Status (BIMS) of 15 that indicated she was cognitively intact. b. [...]

Inspectors wroteBased on record review, staff interview, and review of facility policy and procedure, the facility failed to ensure education was provided prior to offering the influenza and pneumococcal vaccines for four residents (#19, #26, #38, and #162) out of five residents reviewed for vaccines. The facility had a census of 64.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure written authorization forms for the facility to manage resident funds were appropriately completed for three residents (#34, #55, and #188). Additionally, the facility failed to ensure one resident (#55) received his monthly $50 allowance. The facility census was 54.

Inspectors wroteBased on observations, resident interview, staff interview, and review of facility policy and procedures, the facility failed to ensure the personalized air conditioner (PTAC) in Resident #55's room was maintained in a clean manner and the facility also failed to maintain plumbing in Resident #48's bathroom to prevent leaking. This affected two residents (#48 and #55) of 30 residents in the sample. The facility census was 64.

Inspectors wroteBased on record review, staff interview, and review of facility policy and procedures, the facility failed to ensure as needed (PRN) psychotropic medication and antianxiety medication were not ordered for longer than 14 days without a stop date or reassessment for appropriateness. This affected one resident (#21) of five reviewed for unnecessary medication. The facility census was 64.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for two Residents (#21 and #25) of 30 residents reviewed in the sample. The facility census was 64.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a pre-admission screening and resident review (PASARR) was updated after a change in the mental health diagnosis for one resident. This affected one resident (#21) out of four reviewed for PASARR. The facility census was 64.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy and procedure, the facility failed to ensure care plans were developed as appropriate. This affected one resident (#21) of 22 residents reviewed for care planning. The facility census was 64.

Inspectors wroteBased on record review, resident interview, staff interview, and review of policy and procedure, the facility failed to ensure a resident received showers/bed baths as scheduled. This affected one (Resident #24) out of two residents reviewed for activities of daily living (ADLs). The facility census was 64.

Inspectors wroteBased on observations, medical record review, staff interview, family interviews, review of hospital records, and review of the facility policy, the facility failed to ensure a resident, who was identified at risk of nutritional problems and malnutrition, maintained acceptable parameters of nutritional status, and failed to follow nutritional interventions, complete weekly weights as ordered, provide appropriate assistance with meals, and provide appropriate oversight and monitoring to address significant and severe weight loss for Resident #10. This affected one (#10) of five residents (#10, #21, #26, #34, and #35) reviewed for nutrition. The facility identified a total of eight residents (#10, #11, #21, #27, #33, #35, #46 and #58) as being at nutritional risk. The facility census was 64.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to provide oxygen to one resident (#58) out of two reviewed for respiratory care. The facility census was 64. Findings Include: Review of the medical record for Resident #58 revealed an admission date 04/28/25. Diagnoses included chronic systolic heart failure, paroxysmal atrial fibrillation, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #58 had a Brief Interview of Mental Status (BIMS) of 15 that indicated he was cognitively intact. Resident #58 was dependent on turning, personal hygiene, toileting, dressing upper and lower body. [...]

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure pharmacy reviews were followed up on in a timely manner and documentation of the pharmacy recommendations were maintained for one resident (#21) out of five reviewed for pharmacy recommendations. The facility census was 64.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to ensure a medication error rate less than five percent (%). Two errors were observed out of twenty-six opportunities, equaling an error rate of 7.69%. This affected two residents (#59 and #217) out of three residents reviewed for medication administration. The facility census was 64. Findings Include: 1. Review of the medical record for Resident #59 revealed an admission date of 10/05/23. Diagnoses included type two diabetes and developmental disorder of scholastic skills. Review of the physicians order dated 12/09/24 revealed that Resident #59 had an order for Calcium Carbonate 500 milligrams (mg) with instructions to take one tablet by mouth every six hours as needed for indigestion. [...]

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to appropriately and safely store medications and biologicals. This affected two residents (#2 and #217) out of 30 residents in the survey sample. The facility census was 64. Findings Include: 1. Review of the medical record for Resident #217 revealed an admission date 05/08/25. Diagnoses included chronic obstructive pulmonary disease, type two diabetes, gastroesophageal reflux disease, and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #217 had a Brief Interview of Mental Status (BIMS) of 15 that indicated she was cognitively intact. Review of Resident #217's physician orders revealed the resident did not have an order for Calcium Carbonate (TUMS) or an order to have medications unattended at bedside. [...]

Inspectors wroteBased on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure dental services were arranged in a timely manner. This affected three residents (#10, #21, and #50) of four residents reviewed for dental services. The facility census was 64.

Inspectors wroteBased on resident interview, staff interview, and record review, the facility failed to place Resident #26 on the appropriate diet. This affected one resident (#26) out of 30 residents reviewed for the sample. The facility had a census of 64.

Inspectors wroteBased on record review, and interviews, the facility failed to ensure an effective antibiotic stewardship program was being followed/implemented regarding McGeers criteria for one resident (#10) out of four residents reviewed for infections. The facility census was 64.

Inspectors wroteBased on record review, staff interview, and review of facility policy and procedure, the facility failed to ensure education was provided prior to offering the coronavirus (COVID) vaccine for two residents (#26 and #162) out of five residents reviewed for vaccines. The facility had a census of 64.

Inspectors wroteBased on review of the employee files, staff interview, and review of the facility policy and procedure, the facility failed to complete employee reference checks prior to hire and failed to ensure documented evidence of written policies and procedures pertaining to screening potential new employees with employee reference checks prior to hire. This had the potential to affect all facility residents. The facility census was 64.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide appropriately sized incontinence briefs for residents who have bariatric needs. This affected three (Residents #48, #66, and #77) of three bariatric residents reviewed. The facility census was 78.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of facility policies, the facility failed to ensure oxygen tubing was changed monthly due to inadequate supply. This affected one resident (#41) of the four residents reviewed for respiratory care. The facility census was 78.

Inspectors wroteBased on observations, staff and resident interviews, review of the Resident Council food food committee minutes, and policy review, the facility failed to ensure the food was served at the appropriate and safe temperatures to the residents. This had the potential to affect all residents except for one resident (#44) who received all his nutrition via a tube feeding. The facility census was 67.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to complete a baseline care plan for one (Resident #262) out of the two residents reviewed for baseline care plans. The facility census was 62.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to update care plans to ensure plans met the resident's current level of needs. This affected two (Residents #50 and #33) of three reviewed for care planning. The facility census was 62.

Inspectors wroteBased on medical record review, dialysis contract review, and staff interviews, the facility failed to conduct ongoing assessment of a resident related complications prior to and/or post dialysis. The facility also failed to communicate the resident's vital signs and medical status with the dialysis center. This affected the one (Resident #263) resident who received dialysis. The facility census was 62.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete laboratory (lab) orders as directed. This affected one (Resident #22) of three residents reviewed for physician orders. The facility census was 62.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to properly practice proper infection control procedures when providing wound care. This affected one (Resident #46) out of four residents reviewed for infection control procedures during wound care. The facility census was 62.

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to properly store and date food items to prevent contamination and spoilage. This had the potential to affect 59 of 62 residents as the facility identified there residents (Resident #39, #155, and #207) who did not eat by mouth . The census was 62.

Inspectors wroteBased on personnel record review, staffing schedule review, phone email review, staff interview and facility policy review, the facility failed to implement their abuse policy when background checks were not conducted prior to employment and the facility allowed an employee to continue to work when the background check was not received within 30 days. This affected one State Tested Nursing Aide (STNA) #210 of nine personnel records reviewed for background checks. STNA #210 was permitted to work two shifts on Hallway #3, after the 30 days had elapsed. The facility identified Hallway #3 had 14 residents (#4, #6, #10, #12, #14, #23, #37, #39, #44, #46, #47, #48, #54 and #207) who resided there. The census was 62.

Inspectors wroteBased on medical record review, observation, interview, and facilities policy review the facility failed to provide dignity to residents with catheters. This affected two (Resident #18 and Resident #25) out of six residents with catheters. The facility census was 62.

Inspectors wroteBased on review of resident funds, staff and resident interview and facility policy review the facility failed to ensure personal funds money could be obtained on the weekends. This affected one (Resident #11) of four residents reviewed for personal funds. The facility identified 36 residents with personal funds. The facility census was 62.

Inspectors wroteBased on medical record review and staff interview the facility failed to notify a resident and/or the residents representative in writing the reason for the transfer to the hospital. This affected one (Resident #52) of two residents reviewed for transfer and discharge. The facility census was 62.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure a resident with a newly evident mental disorder was referred for a pre-admission screening and resident review (PASARR) upon a significant change. This affected one (Resident #47) of one resident reviewed for PASARR. The facility census was 62.

Inspectors wroteBased on medical record review, staff interview and facility policy review the facility failed to develop a comprehensive care plan to address the behavioral and refusal of care needs. This affected one (Resident #155) of one resident reviewed for the behavioral/emotional care area. The facility census was 62.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to update and revise resident care plans. This affected one (Resident #18) out of 20 residents reviewed for accurate care plans. The facility census was 62.

Inspectors wroteBased on medical record review, observation and interview the facility failed to provide appropriate care for residents with catheters. This affected one (Resident #25) out of six residents with catheters. The facility census was 62.

Inspectors wroteBased on medical record review, staff interview and facility policy review the facility failed to notify the physician of a significant weight loss for Resident #50 and failed to implement fluid restrictions for Resident #31. This affected two (Resident's #31 and #50) of two residents reviewed for change in condition. The facility census was 62.

Inspectors wroteBased on medical record review, observation, staff interview and facility policy review the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS) was completed correctly and timely, behaviors were monitored for an antipsychotic medication, and recommendation from the pharmacy was completed. This affected one (Resident #1) of five reviewed for unnecessary medications. In addition, the facility failed to ensure resident's blood sugars were reported to the physician and pharmacy recommendations were completed. This affected one (Resident #42) of five reviewed for unnecessary medications. The facility census was 62.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review the facility failed to ensure infection prevention procedures were followed. The facility failed to properly clean Resident #205's perineal area during indwelling Foley catheter care. This affected one (Resident #205) of two residents reviewed for catheter care. The facility census was 62.