Cedar Crossings

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 17, 2024

  Based on interview and record review it was determined the facility failed to re-evaluate elopement risks and modify care plan interventions after ongoing elopement attempts and exit seeking behaviors for a resident with cognitive impairment and inability to effectively communicate her/his needs due to aphasia and CVA. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1's elopement from the facility on 6/12/24 and placed residents at risk for an unsafe elopement. Findings include: The facility's 3/2019 Wandering and Elopement policy indicated the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. […]

• Actual harm, isolatedF689Nov 9, 2023

  Based on interview and record review it was determined the facility failed to provide appropriate supervision and implement fall interventions to prevent a resident fall with injury for 1 of 5 sampled residents (#1) reviewed for accidents. This failure resulted in Resident 1 requiring hospitalization and placed all residents at risk for falls. Findings include: Resident 1 was admitted to the facility in 2/2023 with diagnoses including congestive heart failure (chronic heart condition), Stage IV chronic kidney disease and a history of right lower leg amputation. […]

• Actual harm, isolatedF697Apr 27, 2023

  Based on observation, interview and record review it was determined the facility failed to administer pain medication timely for 2 of 3 sampled residents (#s 1 and 7) reviewed for pain management. As a result, both residents complained of severe pain. Findings include: The facility's Pain Assessment and Management: policy, revised 3/2022 defined pain management as the process of alleviating the resident's pain to a level that is acceptable to the resident and based on her/his clinical condition and established treatment goals. 1. Resident 1 admitted to the facility on [DATE] with diagnoses including aftercare for hip replacement surgery and history of pulmonary embolism (blockage of an artery in the lung). […]

• No harm, potential for more than minimal, widespreadF865Jun 17, 2024

  Based on interview and record review, it was determined the facility failed to develop and present a QAPI plan to the State Survey Agency (SSA) and failed to present documentation and evidence of an ongoing QAPI Program. This placed residents at risk of not receiving the care and services for optimal resident outcomes. Findings include: A review of facility QAPI records presented by Staff 1 (Administrator) showed no evidence the facility had developed a QAPI plan. Staff 1 also acknowledged there was no ongoing QAPI program. On 6/17/24 at 11:39 AM, Staff 1 (Administrator) acknowledged the facility had not developed a QAPI Plan.

• No harm, potential for more than minimal, widespreadF868Jun 17, 2024

  Based on interview and record review it was determined the facility failed to have a quarterly QAA (Quality Assessment and Assurance) committee meeting and failed to include the Medical Director reviewed for quality assurance. This placed residents at risk of not receiving the care and services for optimal resident outcomes. Findings include: A review of facility records presented by Staff 1 (Administrator) showed no evidence nor documentation the facility conducted quarterly QAA meetings and with no Medical Director involvement. On 6/17/24 at 11:39 AM Staff 1 (Administrator) acknowledged the facility QAA committee had not met quarterly and the facility's Medical Director had no involvement.