Cedar Creek Post Acute

In the surveyor’s words

From the most serious findings on record at Cedar Creek Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF600Apr 11, 2024

  Based on facility policy review, www.hopkinsmedicine.org/health, Police Incident Report dated [DATE] review, facility investigation review, medical record review and interviews, the facility failed to ensure residents were free from abuse/sexual for 6 of 9 (Residents #3, #7, #9, #11, #14, and #15) sampled residents reviewed for abuse/neglect. On [DATE] during group activities Resident #11, who had a BIMS of 12, approached Resident #15, who had a BIMS of 4, began to rub across her shoulders and back, and then tried to kiss her. Resident #15 told Resident #11 to stop and pushed him away. Resident #11 then put some money on the table in front of Resident #15 and pushed it towards her while saying, If this isn't enough, let me know. […]

• Immediate jeopardy, patternF880Apr 11, 2024

  Based on facility policy review, (Named Glucometer- a device used to check blood sugar levels with the use of a blood sample) User's Guide review, Guidelines for General Use of (Named germicidal cloth) wipes used by the facility review, DME (Durable Medical Equipment) supplier recommendation letter review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not cleaned and disinfected with facility required cleansing wipes to prevent cross-contamination of bloodborne pathogens for 2 of 11 (Residents #17 and Resident #18) sampled residents reviewed for blood glucose monitoring. […]

• Immediate jeopardy, isolatedF580Apr 11, 2024

  Based on policy review, medical record review, and interview, the facility failed to notify and consult the Physician/Nurse Practitioner (NP) of a change in condition related to falls 1 of 6 (Resident #7) sampled residents reviewed for change in condition. On [DATE], Resident #7 had an unwitnessed fall and was found on the floor with his head under the bed. Resident #7 hit his head while being placed back in bed by staff. The Physician/NP was not notified of Resident #7's unwitnessed fall on [DATE], and on [DATE], Resident #7 experienced a change in mental status. […]

• Immediate jeopardy, isolatedF689Apr 11, 2024

  Based on facility policy review, medical record review, facility investigation review, hospital record review, and interview, the facility failed to provide an environment that is free from accident hazards for 1 of 6 (Resident #7) sampled residents reviewed for falls. On [DATE] at 5:30 PM, Resident #7, known to have a history of falls with injury, was found on the floor following an unwitnessed fall from bed. LPN G documented staff (CNA AA and CNA CC) assisted Resident #7 off the floor and Resident #7 hit his head on the bed. CNA AA and CNA CC then placed Resident #7 back in bed. There was no documentation to show a post-fall assessment was completed prior to moving Resident #7 from the floor to the bed. There was no documentation to show neuro checks were conducted. […]

• Actual harm, isolatedF684Oct 25, 2022

  Based on facility policy review, medical record review, and interviews, the facility failed to resume an anticoagulant medication after a surgical procedure for 1 of 3 residents (Resident #2) reviewed, which resulted in the resident suffering a Cerebrovascular Accident (CVA), causing irreversible Harm. The findings include: Review of the facility's policy titled, Medication Reconciliation, revised 11/23/2021, revealed, .Medication Reconciliation/Drug Regimen Review is an interdisciplinary process between Nursing, Medical Staff and Pharmacy that compares the resident's most current list of home medications against the physician's orders upon admission and discharge, addresses discrepancies/issues, and thereby decreases potential Adverse Drug Events (ADEs) and omissions of medication therapy… […]