Ness County Hospital Ltcu Dba Cedar Village

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide Resident (R) 1 with choices in daily routines, activities, schedules, and participation in care decisions when staff did not honor Resident (R) 1's wishes not to be showered and scrubbed.

Inspectors wroteThe facility identified a census of 23 residents, with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to ensure the foot pedals were on Resident (R) 1's wheelchair when staff assisted pushing her in her wheelchair, to prevent avoidable accidents. On 09/12/25, Licensed Nurse (LN) G propelled R1 in her wheelchair, without foot pedals, and R1 put her feet on the ground, which caused R1 to fall headfirst to the floor. R1 sustained a laceration (cut) on her forehead, which measured 7.5 centimeters (cm), a small hematoma, and required emergency transfer to evaluation and eight sutures to close the laceration.

Inspectors wroteThe facility had a census of 22 residents. The sample included 12 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote dignity for one resident, Resident (R) 22, whose pajamas were soiled with urine from her waist down to the back of her knees. The facility further failed to promote dignity for R22 by taking her out into the common area and into an activity in her pajamas. This placed the resident at risk for impaired dignity. [...]

Inspectors wroteThe facility had a census of 22 residents. The sample included 12. Based on observation, record review, and interview, the facility failed to implement effective care plan interventions for Resident (R) 6 from falling and sustaining major injuries. This deficient practice placed R6 at risk for continued falls and injuries.

Inspectors wroteThe facility had a census of 22 residents. The sample included 12 residents, with one reviewed for Activities of Daily Living (ADL). Based on observation, record review, and interview, the facility failed to provide meal assistance for one resident, Resident (R) 19, who required assistance. This placed R22 at risk for further weight loss.

Inspectors wroteThe facility had a census of 22 residents. The sample included 12 residents, with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to prevent the development of a Stage 3 (full thickness tissue loss) pressure ulcer for one resident, Resident (R) 22 who had edema (swelling resulting from an excessive accumulation of fluid in the body tissues) in her legs. The facility also failed to implement interventions to prevent further breakdown and follow the plan of care to wear pressure-relieving boots at all times. This placed the resident at risk for further breakdown.

Inspectors wroteThe facility had a census of 22 residents. The sample included 12 residents of which five residents were reviewed for falls. Based on observation, record review, and interview, the facility failed to prevent Resident (R) 6 from falling and sustaining major injuries with ineffective interventions. This placed R6 risk for continued falls and injuries.

Inspectors wroteThe facility had a census of 22 residents. The sample included 12 residents, with five residents reviewed for falls. Based on observation, record review, and interview, the facility failed to prevent Resident (R) 6 from falling and sustaining major injuries with ineffective interventions. This deficient practice placed R6 at risk for continued falls and injuries.

Inspectors wroteThe facility had a census of 22 residents. The sample included 12 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 4's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for use and that R13's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had an end-of-use date. This placed the residents at risk of receiving unnecessary psychotropic (alters mood or thought) medication.

Inspectors wroteThe facility had a census of 22 residents. The sample included 12 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 4's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for use and that R13's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had an end-of-use date. This placed the residents at risk of receiving unnecessary psychotropic (alters mood or thought) medication.

Inspectors wroteThe facility had a census of 26 residents. Based on record review and interview, the facility failed to provide competent staff with the appropriate training, skills, and knowledge when two Certified Nurse Aides (CNA) administered medication to eight residents, Resident (R) 1, R2, R3,R4, R5, R6, R7, and R8, at the direction of Administrative Nurse D, because the licensed nurse on duty did not feel comfortable passing the medications. This placed the resident's at risk for medication errors and complications related to incompetent staff.

Inspectors wroteThe facility had a census of 25 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 3's plan of care to include collaboration of care with the hospice (specialized care related to end of life) service and failed to include R16's use of antipsychotic (medication used to treat psychosis-any major mental disorder characterized by a gross impairment in reality testing) medication. The deficient practice placed R3 and R16 at risk for unmet care needs.

Inspectors wroteThe facility had a census of 25 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 16 the appropriate treatment and services to attain highest practicable mental and psychosocial (interrelation of social factors and individual thought and behavior) well-being, when staff failed to provide R16 with behavioral health services. This placed the resident at risk for unmet behavioral health care needs.

Inspectors wroteThe facility had a census of 25 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 1's physician-ordered medication regimen lacked indications for use. This placed the resident risk of unnecessary or ineffective medication therapy.

Inspectors wroteThe facility had a census of 25 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1's physician-ordered medications included an indication for use. This placed the resident risk of unnecessary or ineffective medication therapy.

Inspectors wroteThe facility had a census of 25 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label two insulin (hormone that lowers the level of glucose in the blood) vials with an open date and an expiration date. This deficient practice placed Residents (R) 1 and R20 at risk to receive expired insulin.

Inspectors wroteThe facility identified a census of 25. The sample included 12 residents with five reviewed for medications. Based on observation, interview, and record review, the facility failed to implement antibiotic use protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk of adverse events, including antibiotic resistance, when the facility failed to monitor effectiveness and identify inappropriate extended administration of antibiotic eyedrops for Resident (R) 1. This placed the resident at risk for complications related to antibiotic use.

Inspectors wroteThe facility had a census of 15 residents. The sample included eight residents, with three reviewed for accidents. Based on observations, record review, and interview, the facility failed to revise one of eight care plans, Resident (R) 4.

Inspectors wroteThe facility had a census of 15 residents. The sample included eight residents, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to prevent accidents for one of three sampled residents, Resident (R) 4, who had bruises on her left forearm and hand.