Cedar Crest at North Florida

In the surveyor’s words

From the most serious findings on record at Cedar Crest at North Florida, in the surveyor’s own words.

• Immediate jeopardy, patternF726Oct 10, 2025

  Based on interview and record review, the facility failed to ensure 2 of 6 reviewed licensed practical nurses (Staff H, and Staff J) had the specific competency requirements as part of their license and certification to administer IV (intravenous) medications, and 4 of 6 reviewed licensed practical nurses (Staff A, Staff B, Staff E, and Staff G) failed to follow the policy/procedure related to IV medication administration, physician notification, and obtaining stat [derived from the Latin word statim, meaning immediately] orders for medication and equipment for 3 of 3 residents reviewed for intravenous antibiotic medication (Residents #1, #3, and #4), the facility failed to ensure 4 of 6 licensed practical nurses (Staff A, Staff B, Staff J, and Staff L) failed to follow physician-ordered… […]

• Immediate jeopardy, isolatedF600Oct 10, 2025

  Based on interview and record review, the facility failed to ensure all residents were free from medical neglect by failing to ensure staff implemented the policies and procedures for medication administration for 1 of 3 residents reviewed for intravenous (IV) antibiotic medication administration (Resident #1). The facility failure to ensure residents were free from medical neglect by failing to ensure residents were free from significant medication errors when the residents were not administered the prescribed antibiotics per the physician order and failure to ensure the nursing staff had appropriate IV (intravenously) certification to administer IV medications and follow the policy/procedure related to medication administration, physician notification, obtaining stat [derived from the… […]

• Immediate jeopardy, isolatedF760Oct 10, 2025

  Based on interview and record review the facility failed to ensure residents were free from significant medication errors when the facility failed to ensure residents were administered physician ordered antibiotics for 1 of 3 residents reviewed for intravenous (IV) antibiotic medication (Resident #1). The facility failure to ensure residents were free from significant medication errors when the residents were not administered the prescribed antibiotics per the physician order resulted in Immediate Jeopardy. Resident #1 was admitted on [DATE] with physician orders for Vancomycin 1500 mg IV every 8 hours intravenously for infection (osteomyelitis, an infection in the bone). On 9/8/2025 at approximately 10:00 PM, Resident #1 was administered one incorrect dose of Vancomycin 1000 mg. […]

• Immediate jeopardy, isolatedF600Nov 19, 2024

  Based on interview, record review, and review of policy and procedures, the facility failed to ensure the residents were free from medical neglect by failing to implement the policies and procedures for neglect for 1 (Resident #1) of 3 residents reviewed for insulin administration. On 10/6/2024 at 6:00 AM, Resident #1 had a blood sugar value of 552 and the on-call provider was notified of the value and the resident stated he was refusing medications until he received the proper insulin. Staff A, Licensed Practical Nurse, (LPN), did not communicate to Staff B, LPN or transcribe the new orders into the medical record for the increase in insulin and the addition of sliding scale insulin coverage. […]

• Immediate jeopardy, isolatedF684Nov 19, 2024

  Based on interview, record review, and review of policy and procedures, the facility failed to ensure residents who required insulin administration received treatment in accordance with professional standards of practice by failing to notify and immediately consult with the resident's physician when a resident suffered elevated blood glucose levels. On 10/6/2024 at 6:00 AM, Resident #1 had a blood sugar value of 552 and the on-call provider was notified of the value and the resident stated he was refusing medications until he received the proper insulin. Staff A, Licensed Practical Nurse, (LPN), did not communicate to Staff B, LPN or transcribe the new orders into the medical record for the increase in insulin and the addition of sliding scale insulin coverage. […]