The Cedars

Inspectors wroteThe facility had a census of 33. The sample included 12 residents. Based on record review, interview, and observation, the facility failed to provide care for Resident (R) 23 who had a Brief Interview for Mental Status (BIMS) score of eleven, which indicated moderately impaired cognition in a manner that protected and promoted their dignity.

Inspectors wroteThe facility has a census of 33 residents. The sample included 12 residents, with three reviewed for Beneficiary Notices. Based on interview and record review, the facility failed to provide two sampled residents, Resident R9 and R28 (or their representative), with the completed Notice of Medicare Non-Coverage (NOMNC) Form 10123, Centers for Medicare and Medicaid Services (CMS).

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication or a documented physician rationale, which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R) 11's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. The facility further failed to ensure R5 and R31's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date. Findings Included: [...]

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents, with one reviewed for discharge. Based on the interview and record review, the facility failed to complete a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of Resident (R) 49's stay.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to implement interventions for diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or he body cannot respond to the insulin) management for one resident, Resident (R) 2, and failed to implement individualized fall interventions for one resident, R31.

Inspectors wroteThe facility had a resident census of 33. The sample included 12 residents, of whom seven were reviewed for accidents. Based on observation, interview, and record review, the facility failed to follow the plan of care for one resident, Resident (R) 9, who had falls in his room and a fall with injury because his shoes were too big. The facility failed to provide a safe environment for R43, who had two falls involving the sit-to-stand lift (which helps transfer residents from one seated surface to another) and did not follow the plan of care.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to obtain blood sugar parameters from the physician for one resident, Resident (R) 2, who had her blood sugar taken four times per day.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents, with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attends to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 23.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 33 residents who resided in the facility and received their meals from the kitchen.

Inspectors wroteThe facility had a census of 31 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure staff identified an allegation of rough care as potential abuse and reported immediately to the Licensed Nursing Home Administrator (LNHA). The facility further failed to report the allegation of abuse to the State Agency (SA) as required. This placed the resident at risk for ongoing abuse and mistreatment.

Inspectors wroteThe facility had a census of 31 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to initiate protective measures and fully investigate an allegation of abuse for Resident (R) 1. This placed the resident at risk for ongoing abuse.

Inspectors wroteThe facility had a census of 37 residents. The facility had one main kitchen and three kitchenettes. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 37 residents who received their meals from the facility's kitchens when staff stored unlabeled, undated food in the refrigerators. Staff did not sanitize the thermometer between food items when checking food temperatures and failed to ensure clean and sanitary preparation areas. This placed the 37 residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 37 residents. Based on observation, record review, and interview, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 37 residents. The sample included 15 residents with one reviewed for dignity. Based on observation, record review, and interview the facility staff failed to treat Resident (R) 29 with dignity when staff checked his blood glucose level at the dining room table with two other residents able to view the procedure. This placed the resident at risk for an undignified experience.

Inspectors wroteThe facility had a census of 37 residents. The sample included 15 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide the resident (or their representative) a fully completed Advanced Beneficiary Notice (ABN) for skilled services for Resident (R) 16, R17, and R190 which included the estimated cost of services. This placed the resident at risk for uninformed care decisions.

Inspectors wroteThe facility had a census of 37 residents. The sample included 15 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent avoidable accidents. This placed the resident at risk for further accidents due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to assess and treat Resident (R) 32's alteration in bowel movements, which placed the resident at risk of ongoing constipation and possible fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move) complications.

Inspectors wroteThe facility had a census of 37 residents. The sample included 15 residents, with one 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 implement nutritional interventions to promote healing for one resident, Resident (R) 11, after development of a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcer. This placed the resident at risk for complications from pressure injuries and delayed healing.

Inspectors wroteThe facility had a census of 37 residents. The sample included 15 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure an environment free from preventable accident hazards for Resident (R) 7, who spilled her hot tea onto her lap twice in one week. This placed the resident at risk for injury.

Inspectors wroteThe facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 32 with sanitary indwelling catheter (tube placed in the bladder to drain urine into a collection bag) care and treatment which placed the resident at risk for urinary tract infections (UTI).

Inspectors wroteThe facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide appropriate respiratory care and services when staff failed to store oxygen cannula and tubing in a sanitary manner for Resident (R) 14. This placed the resident at risk for respiratory infections.

Inspectors wroteThe facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to prepare a nourishing well well-balanced pureed diet that followed the menu and included a vegetable for Resident (R)190, who requested vegetables. This placed the resident at risk for dissatisfaction and impaired nutrition.

Inspectors wroteThe facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure adequate infection control measures when staff did not practice appropriate hand hygiene when providing incontinence care for Resident (R) 12, or for R4 during medication administration. This placed the residents at risk for infection.

Inspectors wroteThe facility had a census of 51 residents. The sample included 13 residents with one reviewed for abuse. Based on observation, record review, and interview, the facility failed to prevent an incident of abuse and/or retaliation for Resident (R)23, when agency Licensed Nurse (LN) G refused to give R23 his evening medications then took the residents cell phone out of his hand, threw it in the recliner, refused to let the resident to call the police and then transferred R23 using a lift whereas R23 sustained a skin tear during the transfer. This deficient practice placed R23 at risk for physical injury and impaired psychosocial wellbeing.

Inspectors wroteThe facility reported a census of 51 residents. The sample included 13 residents with one reviewed for quality of life. Based on observation, record review, and interview, the facility failed to ensure all staff honored and responded to Resident (R)23's preferences, requests and choices to ensure R23's quality of life. This deficient practice placed R23 at risk for decreased psychosocial wellbeing and impaired dignity and autonomy. Findings Included: [...]

Inspectors wroteThe facility had a census of 51 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to ensure staff possessed the appropriate skills and competencies when staff failed to complete post-fall neurological assessments for one of three residents reviewed for accidents, Resident (R) 9. This placed R9 at increased risk for unrecognized fall related injury and delayed treatment.

Inspectors wroteThe facility had a census of 51 residents. The sample included 13 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to follow up on the consultant pharmacist recommendations to ensure the facility obtained a risk versus benefit statement annually for the continued use of Seroquel (antipsychotic drug) for R42 and an appropriate diagnosis for the use of Seroquel for R16. This deficient practice placed R16 and R42 at risk for unnecessary drugs.

Inspectors wroteThe facility had a census of 51 residents. The sample included 13 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure two sampled Residents (R) did not receive unnecessary psychotropic medications (class of medications which alter mood or thought) when they failed to obtain a risk versus benefit statement for the continued use of Seroquel (antipsychotic drug) for R42 and an appropriate diagnosis for the continued use of Seroquel for R16. This deficient practice placed R16 and R42 at risk to receive unnecessary psychotropic drugs.

Inspectors wroteThe facility had a census of 51 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to ensure one of seven residents reviewed during medication administration pass remained free of medication errors. This deficient practice placed Resident (R) 23 at risk for adverse reaction from the medication.