The Gardens at Cedarwood

Inspectors wroteBased on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 2 2025 (January 1 -March 31) in accordance with the schedule specified by CMS.

Inspectors wroteBased on record review and interview, the facility failed to ensure a [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was active and current for administration of an antipsychotic medication for one Resident (#10), out of a total sample of 14 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR- Preadmission screening for residents with a mental disorder or intellectual disability) was accurately completed prior to the admission of one Resident (#4), in a total sample of 14 residents.

Inspectors wroteBased on document review and interview, the facility failed to ensure that monthly medication regimen reviews (MRR) were communicated to the physician and addressed in a timely manner for one Resident (#1), out of a total sample of 14 residents. Specifically, the facility failed to ensure recommendations from August and September 2024 by the pharmacy consultant to evaluate continued use of as needed Geri-tussin (cough syrup) and menthol lozenge was reviewed and responded to by the provider in a timely manner.

Inspectors wroteBased on observations, document review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for one Resident (#207), of 14 sampled residents. Specifically, the facility failed to ensure his/her indwelling Foley catheter (tube inserted into the bladder to drain urine into a collection bag outside the body) was maintained in a sanitary manner.

Inspectors wroteBased on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 1 2024 (October 1 - December 31) in accordance with the schedule specified by CMS.

Inspectors wroteBased on observation, document review, policy review, and interviews, the facility failed to: 1. Maintain an infection prevention and control program with a complete system of surveillance to identify any trends of actual or potential infections within the facility; 2. For Resident #36, ensure staff wore personal protective equipment (PPE) as required for Enhanced Barrier Precautions (EBP); 3. For Resident #160, ensure EBP were implemented, and PPE was utilized when providing high contact resident care; and 4. Ensure policy and procedures for EBP were developed and implemented, effective 4/1/24 as required.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed to ensure the residents' rooms and environment were maintained in good repair and homelike on 2 of 2 resident care units.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to provide adequate supervision and an environment free from accidents and/or hazards for three Residents (#4, #19, and #26), out of a total sample of 15 residents. Specifically, the facility failed: 1. For Resident #4, to follow their fall Reduction policy for investigating falls and initiating fall prevention interventions; 2. For Resident #19, to follow their fall Reduction policy for investigating falls and initiating fall prevention interventions; and 3. For Resident #26, to follow their Elopements and wandering residents policy for assessing risk factors and implementing interventions to prevent further elopements. Findings Include: 1. Review of the facility's policy titled Fall Reduction, dated as last revised [DATE], indicated but was not limited to the following: - Goal: [...]

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed for four Residents (#53, #54, #34, and #1), out of a sample of 15 residents, to ensure staff provided respiratory care and services consistent with professional standards of practice. Specifically, the facility failed: 1. For Resident #53, to ensure orders were in place for Oxygen and the equipment/tubing was changed per policy; 2. For Resident #54, to ensure a Respiratory care plan was developed and the nebulizer equipment/tubing/mask were stored and changed per policy; 3. For Resident #34, to ensure nebulizer equipment was clean and mask/tubing were stored per policy; and 4. For Resident #1, to ensure the oxygen equipment/tubing was changed per policy.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for three Residents (#21, #9, and #19), out of 5 residents selected for an unnecessary medication review. Specifically, the facility failed: 1. To ensure facility wide recommendations were addressed timely and maintained as part of the medical record; 2. For Resident #21, to ensure the January, February, and March 2024 consultant pharmacist recommendations were acted upon timely and to ensure the January, February, March, and April 2024 consultant pharmacist recommendations were maintained as part of the permanent medical record; 3. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed: 1. For Resident #50, to ensure the medications were administered under direct supervision and not left at the bedside; 2. To ensure medication and treatment carts on Unit One were locked when not in direct supervision of the licensed nurse; and 3. Ensure safe storage of medications and biologicals according to current standards of practice in 2 of 2 observed medication carts.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer pneumococcal vaccinations per facility policy and the Centers for Disease Control and Prevention (CDC) recommendations for three Residents (#9, #13, and #34), out of a total sample of five residents reviewed for immunizations.

Inspectors wroteBased on the Beneficiary Protection Notification Review, interview, and policy review the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055 and the Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123, were provided timely and explained to the resident/resident representative for two Residents (#19 and #49), out of three sampled residents. Specifically, the facility failed to issue the SNF ABN and failed to issue and explain the NOMNC timely ensuring the Resident/Resident representative understood the appeal process.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure staff developed and implemented a baseline care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident and provide the resident and/or their representative with a summary of the baseline care plan for two Residents (#52 and #109), out of a total sample of 15 residents. Specifically, the facility failed: 1. For Resident #52, to provide him/her a written summary of the baseline care plan by completion of the comprehensive care plan and document receipt of the information within the Resident's clinical record; and 2. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to implement interventions on the Falls Care Plan for one Resident (#21), out of a total sample of 15 residents to meet the resident's physical, psychosocial and functional needs.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#46), out of a total sample of 15 residents. Specifically, the facility failed to ensure nail care was performed for Resident #46.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for three Residents (#34, #160, and #16), out of a total sample of 15 residents. Specifically, the facility failed: 1. For Resident #34, to ensure the Foley catheter was assessed for removal as soon as possible or determine a clinical condition related to Foley catheter placement on admission to the facility; 2. For Resident #160, to ensure orders were in place for the Foley catheter and Foley catheter care, and to ensure the Foley catheter bag was hung at an appropriate level, below the bladder to discourage backflow of urine which helps prevent urinary tract infections (UTIs); and 3. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure one Resident (#109), out of a sample of 15 residents, received culturally competent, trauma-informed care accounting for resident experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, the facility failed to assess Resident #109 and identify triggers of trauma to prevent potential re-traumatization.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure for one Resident (#15), out of a sample of 15 residents, that their as needed (PRN) psychotropic medication, Lorazepam (antianxiety), was re-evaluated 14 days after the medication was prescribed to ensure it was beneficial and necessary for the Resident in accordance with the standard of practice.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the Resident's status for three Residents (#4, #1, #160), out of a sample of 15 residents. Specifically, the facility failed: 1. For Resident #4, to accurately reflect falls sustained in the facility; 2. For Resident #1, to accurately reflect hospice services; and 3. For Resident #160, to accurately reflect the use of a Foley catheter.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain medical records securely and accurately in accordance with accepted professional standards for one Resident (#3), out of 15 sampled residents. Specifically, the facility failed to ensure Resident #3's electronic medical record contained scanned documents pertaining only to Resident #3.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a been diagnosed with a deep vein thrombosis (DVT), with new orders from the Nurse Practitioner for an anticoagulant medication to be started, the Facility failed to ensure nursing notified Resident #1's Physician, when his/her medication was unavailable to be administered in accordance with his/her Physician orders, as a result Resident #1 did not receive his/her first scheduled dose, he/she was transferred to the Hospital Emergency Department (ED) for evaluation and was admitted .

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a been diagnosed with a deep vein thrombosis (blood clot, DVT), with new orders from the Nurse Practitioner for an anticoagulant (blood thinner) medication to be administered, the Facility failed to ensure nursing notified the correct Pharmacy in order to obtain Resident #1's medication in a timely manner, as a result Resident #1 did not receive his/her first scheduled dose as ordered and he/she was transferred to the Hospital for evaluation.

Inspectors wroteBased on observation, interview, policy review, and document review, the facility failed to ensure the dish machine temperatures were monitored to ensure the machine was reaching temperatures to clean and sanitize the dishes as required per the manufacturer.

Inspectors wrote4. Resident #4 was admitted to the facility in April 2019. Review of the medical record for Resident #4 included a Physician's Interim Order, dated 1/12/23 to collect a stool specimen to rule out c-difficile (c-diff) (a bacterial infection in the colon). The interim order was observed in the medical record on 1/12/23 at 4:00 P.M. Review of the Nursing Progress note, dated 1/12/23, indicated Resident #4 had a foul smelling bowel movement overnight and that morning. The note indicated the Nurse Practioner had been in earlier that afternoon and ordered for a stool collection sample to be sent out to rule out a c-diff infection and parasites. On 1/12/23 at 4:00 P.M., the surveyor observed the room of Resident #4 to not have any precaution signs or a precaution cart to provide supplies to care for the Resident with a possible infection. [...]

Inspectors wroteBased on interview and document review, the facility failed to resolve concerns brought forward during Resident Council meetings.

Inspectors wroteBased on observations, the facility failed to ensure that residents had a homelike environment.

Inspectors wroteBased on observation, interview, and policy review, the facility failed for seven Residents (#7, #9, #13, #16, #19, #47, and #159) to address and resolve voiced grievances regarding the television reception at the facility.

Inspectors wroteBased on observation, interviews, policy review, and record review, the facility failed to follow professional standards of practice for three Residents (#32, #4 and #29), in a total sample of 14 residents. Specifically, the facility failed: 1. For Resident #32, to follow physician's orders to change a dressing for a suprapubic catheter (tube inserted in the belly to drain the bladder); 2. For Resident #4, a. To implement the bowel protocol, b. To follow hospital recommendations for bowel medications following a fecal impaction, and c. To accurately follow physician's orders for bowel regimen medications; and 3. For Resident #29, to ensure a pacemaker was monitored per the professional standards of practice.

Inspectors wroteBased on observations, interviews, medical record review, and maintenance record review, the facility failed to ensure the resident environment remained as free from accidents and hazards as possible. Specifically, the facility failed to: 1. Implement interventions to reduce the potential for a resident to resident altercation between Resident #26 and Resident #38; and 2. Ensure water temperatures were maintained at safe and comfortable levels in resident bathrooms.

Inspectors wroteBased on interview and record review, the facility failed for seven Residents (#9, #25, #4, #48, #29, #35, and #57) to maintain a medical record that was accurate and complete, out of a total sample of 14 residents and three closed records. Specifically, the facility failed to: 1. Identify and correct a sudden documented change in wound classification for Resident #9; 2. Ensure consultant information was available in the medical record for Resident #25; 3. Ensure Physician Progress Notes were readily accessible for Residents #4, #48, #29, and #35; 4. Maintain complete and accurate activities of daily living (ADL) documentation for Resident #35; and 5. Reflect the accurate code status for Resident #57.

Inspectors wroteBased on record review, document review, and interview, the facility failed to implement an antibiotic stewardship program to determine if antibiotics were prescribed for the appropriate diagnosis by ensuring cultures were obtained prior to the start of an antibiotic.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to document the recapitulation of the Resident's stay that included pre- and post-discharge medications for two Residents (#57 and #58) of two closed records reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#24) received the proper treatment to maintain hearing abilities, out of a total sample of 14 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to safely store medications on two of two units. Specifically, the facility failed to: 1. Maintain a temperature log that reflected a minimum of daily temperature checks in the first-floor medication room; and 2. Ensure medication carts were secured when not in view of the licensed nurse.

Inspectors wroteBased on interviews, policy review, and record review, the facility failed to assist a Resident (#35) in obtaining recommended dental services, in a total sample of 14 residents.

Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary environment for one Resident (#9), out of a total sample of 14 residents. Specifically, the facility failed to ensure the wheelchair for Resident #9 was clean and sanitary.