Cedar Grove Respiratory and Nursing Center

In the surveyor’s words

From the most serious findings on record at Cedar Grove Respiratory and Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812May 18, 2023

  Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 05/03/2023 from 08:32 to 09:04 AM, the surveyor, accompanied by the Dietary Director (DD), observed the following in the kitchen: 1. On an upper shelf under the refrigeration unit of the walk-in refrigerator, an opened box contained individual packets of [NAME] Sour Cream. The packets had a use by date of [DATE]. The DD removed the box of individual sour cream packets to the trash. 2. […]

• No harm, potential for more than minimal, patternF656Feb 23, 2022

  Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to develop a person-centered comprehensive care plan (CP) or develop a person-centered comprehensive care plan in a timely manner a) addressing the placement and care of hand mitts on left/right hands (Resident #23), b) addressing the use, care, cleaning and storage of a nebulizer (a machine that delivers aerosol medication into the lungs) (Resident #126), and c) failure to develop a hospice care plan in a timely manner for a resident enrolled and disenrolled in hospice services (Resident #69) . […]

• No harm, potential for more than minimal, patternF888Feb 23, 2022

  Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to A) develop and implement a policy to track facility staff vaccination status to ensure all eligible staff were vaccinated by the required dates and B) follow their own policy for contingency plans by not ensuring unvaccinated staff wore an N 95 mask to mitigate the potential spread of COVID-19. This deficient practice was evidenced by the following: On 2/11/22 during entrance conference, the facility was asked to provide a matrix of the vaccination status of all their staff. The facility provided a sheet of paper, separated by department, and listed the number of total vaccinated and unvaccinated staff. […]

• No harm, potential for more than minimal, isolatedF584May 20, 2025

  During rounds on 05/15/2025 at 09:39 AM survey #2 observed the wardrobe door in room [ROOM NUMBER]-unit B peeling off with sharp edges. During an interview on 05/20/2025 at 09:25 AM with surveyor #2, the Acting Maintenance Director (AMD) said they inspect random rooms weekly. The AMD said that when they see furniture in need of repair, they order replacement furniture it can sometimes take two weeks to a month to be replaced. When asked if there should be peeling furniture in residents' rooms, the AMD said no it can be a dignity and safety issue. […]

• No harm, potential for more than minimal, isolatedF693May 20, 2025

  Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to administer Tube Feedings per Physician's order (PO). This deficient practice was identified for 1 of 5 residents (Resident #82) reviewed for receiving nutrition via Tube Feeding (TF) and was evidenced by the following: On 05/14/2025 09:08 AM, the surveyor entered Resident # 82's room and observed the resident in bed. The surveyor observed that the resident had a TF (nutrition received through a flexible tube surgically inserted into the stomach) formula hanging on a pole, attached to a TF pump, and infusing at a rate of 55 ml/hr (milliliters per hour). On 05/14/2025 at 1:04 PM, the surveyor observed Resident #82 in the bed. […]