Cedarwood Plaza

Inspectors wroteBased on record reviews, observation, interviews and facility policy review, the facility failed to ensure Residents #9, #35 and #36 received a two-gram sodium (low sodium) and/or cardiac diet as ordered. This affected three residents (#9, #35, and #36) out of four residents reviewed for therapeutic diets but had the potential to affect an additional six residents (#3, #7, #42, #54, #70, and #84) the facility identified as being on a two-gram sodium and/or a cardiac diet. The facility census was 102.

Inspectors wroteBased on observations, interviews, record reviews, review of facility menus and facility policy review, the facility failed to ensure the zucchini and onions were palatable and served at a preferred temperature and failed to ensure the noodles were palatable for lunch on 10/08/25. This affected five residents (#5, #29, #41, #60, and #100) out of five residents reviewed for meal palatability but had the potential to affect an additional 94 residents the facility identified as receiving meals from the kitchen. The facility identified three residents (#21, #43, and #55) as not receiving meals from the kitchen. The facility census was 102.

Inspectors wroteBased on observations, interviews, food temperature log review and facility policy review, the facility failed to ensure the mechanical soft chicken was held at a safe holding temperature for lunch on 10/08/25, which had the potential to affect 18 residents (#3, #4, #8, #10, #11, #15, #20, #22, #30, #42, #45, #52, #61, #63, #69, #82, #93, and #99) the facility identified as receiving a mechanical soft diet. The facility census was 102.

Inspectors wroteBased on record review, observation, interview, review of infection surveillance logs and review of facility policy, the facility failed to ensure catheter care was performed per appropriate standards of practice to mitigate the potential for contamination and urinary tract infection. This affected one resident (#6) of one resident reviewed for catheter care and had the potential to affect four additional residents (#2, #49, #59, and #90) who the facility identified as having indwelling urinary catheters. The facility census was 102.

Inspectors wroteBased on medical record review, interviews, hospital record review and facility policy review, the facility failed to timely address a significant weight loss for Resident #104. This affected one resident (#104) out of three residents reviewed for nutrition. The facility census was 102.

Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to ensure proper infection control procedures were followed during care for Resident #6, including appropriate donning and doffing procedures with use of personal protective equipment (PPE), appropriate catheter care, and proper handling of soiled linen and other soiled items. This affected one resident (#6) of one resident reviewed for catheter care and had the potential to affect all 16 residents (#6, #10, #19, #28, #31, #33, #43, 348, #56, #63, #68, #71, #75, #78, #98, and #102) who resided on the North unit of the second floor. The facility census was 102.

Inspectors wroteBased observation, staff interview, and policy review, the facility failed to maintain the kitchen in a clean and sanitary condition. This had the potential to affect all 104 residents residing in the facility. The facility census was 104.

Inspectors wroteBased observation and staff interview, the facility failed to maintain its dumpster area in a clean and sanitary condition. This had the potential to affect all 104 residents residing in the facility. The facility census was 104.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the correct serving sizes and all menu items were provided per the menu. This affected four residents (#28, #43, #55, and #99) but had the potential to affect all residents, except two residents (#36 and #51) who received nothing by mouth. The facility census was 101.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dry silverware and serve food in a sanitary manner. This had the potential to affect all residents except two (#36 and #51) who received nothing by mouth. The facility census was 101.

Inspectors wroteBased on observation and interview, the facility did not ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 111 residents receiving meals from the kitchen excluding Resident #36 and #51 who the facility identified as eating nothing by mouth. The facility census was 113.

Inspectors wroteBased on observation, interview and review of facility policy, the facility did not ensure palatable food was served to all residents receiving meals from the kitchen. This affected six residents (#24, #28, #29, #32, #43 and #87) of six residents reviewed for food service. The facility census was 113.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provided timely incontinence care to the residents. This affected two (Residents #10 and #74) of three residents reviewed for incontinence care. The facility census was 110.

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when caring for a resident on the South unit who had orders for Enhanced Barrier Precautions (EBP). This affected one Resident (Resident #51) of three residents reviewed for infection control, and had the potential to affect an additional 23 residents (#33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #52, #53, #54, #55 and #56) living on the South unit. The facility identified 24 residents in EBP (Residents #4, #10, #11, #14, #20, #27, #30, #31, #33, #41, #47, #48, #50, #51, #52, #54, #58, #75, #81, #86, #87, #88, #97, and #103). The facility census was 106.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, resident and staff interview, review of a police report and review of facility policy, the facility failed to provide a safe environment free from a potential accident hazard when State Tested Nursing Assistant (STNA) #563 was found to have an unsecured loaded firearm in the facility. This resulted in Immediate Jeopardy and potential for serious life-threatening harm when STNA #563 left a loaded firearm, with additional rounds of ammunition, wrapped in a fleece vest and in a clear plastic bag, unsecured on a cart on the 3 North Hallway where residents resided and had access to the bag. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure food items were stored and prepared in a safe and sanitary manner. This had the potential to affect all 101 residents residing in the facility. The facility census was 101. Findings Include: A tour of the facility kitchen was completed on 03/06/24 between 8:15 A.M. and 8:33 A.M. with Dietary Manager #200. Observation of the walk-in cooler revealed a box containing approximately six raw carrots and noted the carrots to be significantly brown in color with significant areas of rot on them, a large box of green peppers with soft exterior skins and numerous other peppers were discolored with various areas of brown and black rot, and a bag of fresh heads of lettuce with significant areas of rot and brown spots on the lettuce. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and facility policy review the facility failed to ensure proper physical assistance was provided to prevent a fall. This affected one resident (#107) of three residents reviewed for falls.

Inspectors wroteBased on observations, interview, and facility policy review the facility failed to ensure that the kitchen was clean and sanitary. This had the potential to affect 95 residents who consumed meals from the facility's kitchen. Residents (#1, #6, #27, #46, #85, and #87) were identified as receiving nothing by mouth. The facility census was 101.

Inspectors wroteBased on observation, interview, and taste test the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected five residents (#8, #26, #42, #55, and #94) who were prescribed pureed diets of 95 residents who consumed meals from the facility's kitchen. Residents (#1, #6, #27, #46, #85, and #87) were identified as receiving nothing by mouth. The facility census was 101.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure call lights were within reach and accessible for Resident #23 and Resident #29. This affected two residents (#23 and #29) of 101 residents reviewed for call light placement.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #33's advance directives were correct in the medical record. This affected one resident (#33) of 29 residents reviewed for advanced directives. The facility census was 101. Findings Include: Review of the medical record for Resident #33 revealed the electronic charting revealed the resident was a full code. Review of the physician's orders revealed Resident #33 had an order for full code. Review of the hard chart revealed a Do Not Resuscitate (DNR) form dated 04/21/23. Interview on 09/25/23 at 9:50 A.M. with Licensed Practical Nurse (LPN) #820 verified the electronic charting had Resident #33 advance directive as a full code and the hard chart had an advance directive form stating Resident #33's code status was DNR. LPN #820 verified the two-code statuses did not match.

Inspectors wroteBased on record review, observation, interview, and facility policy review the facility failed to ensure therapeutic diets were provided to residents. This affected one resident (#30) of six residents reviewed for nutrition services. The facility census was 101.

Inspectors wroteBased on observation, record review, staff interview, and facility policy review the facility failed to ensure residents who required continuous tube feeding received uninterrupted administration of enteral formula. This affected two residents (#46 and #87) of two residents reviewed for tube feeding. The facility identified six residents (#1, #6, #27, #46, #85, #87) who received no food by mouth and three residents (#55, #62, #94) who received supplemental tube feed. The facility census was 101.

Inspectors wroteBased on record review and interview, the facility failed to ensure blood laboratory orders were carried out appropriately. This affected one resident (#79) of five residents reviewed for unnecessary medications. The facility census was 101.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified dietitian. This affected all 110 facility residents.

Inspectors wroteBased on interview and record review, the facility did not ensure the accuracy of the assessments. This affected two (Residents #350 and #99) of 30 resident records reviewed for assessments. The facility census was 110 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that interventions were put into place to prevent falls. This affected one (Resident #350) of four resident records reviewed for falls.

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy consultations were reviewed and addressed by the physician in a timely manner. This affected one (Resident #13) of five residents reviewed for unnecessary medications. The facility census was 110 residents.

Inspectors wroteBased on interview and beneficiary notice review, the facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNABN) CMS 1055 notices to two of two Residents (#42 and #49) who were notified their skilled services would end and would be remaining in the facility of three Residents (#42, #49, and #306) reviewed for beneficiary protection notification. The facility census was 107.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to provide meals that were palatable and at an appropriate serving temperature. This affected one (Resident #86) of five residents reviewed for food complaints and had the potential to affect eight residents (Residents #18, #38, #50, #61, #86, #95, #105, and #109) on a pureed diet. The facility census was 107.