Cedar Haven Operations LLC DBA Lake Forest Health

In the surveyor’s words

From the most serious findings on record at Cedar Haven Operations LLC DBA Lake Forest Health, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880May 6, 2021

  Based on surveyor observation, record review and staff interview it has been determined that the facility failed to implement infection control measures for the prevention of the spread of Coronavirus Disease (COVID-19) relative to properly screening everyone entering a healthcare facility for signs and symptoms of COVID-19. The facility also failed to ensure that healthcare personnel (HCP) utilized Personal Protective Equipment (PPE) according to professional standards to prevent the potential of the transmission of COVID-19 for 1 of 4 units observed, Pavilion unit. […]

• Immediate jeopardy, widespreadF684Jan 11, 2021

  Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 6 of 6 COVID-19 positive residents, Resident ID #'s 1-6. This failure resulted in an actual decline in a resident's physical well-being, Resident ID #1. Findings are as follows: During an interview on 1/11/2021 at 12:57 PM with the Infection Preventionist, he revealed that the facility had a COVID-19 outbreak in December of 2020. During the month of December through 1/11/2021, a total of 90 residents and 46 staff tested positive for COVID-19. Additionally, he stated that 16 COVID-19 positive residents had passed away during this same time period. […]

• Immediate jeopardy, isolatedF726Nov 25, 2025

  Based on record review and staff interview it has been determined that the facility failed to ensure nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care, for 1 of 1 resident reviewed for significant medication errors, Resident ID #1. The failure of the facility to ensure that nursing staff followed established medication administration protocols, adhered to scope-of-practice requirements, and maintained safe medication-handling practices resulted in significant medication errors. […]

• Immediate jeopardy, isolatedF760Nov 25, 2025

  Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed who was administered an antipsychotic, antidiabetic agents, benzodiazepines (medications that are prescribed to slow down activity in your brain and nervous system), and narcotic medications that were prescribed for another resident, who required Emergency Medical Services (EMS), hospitalization, multiple doses of Narcan (a medication used to treat an opioid overdose) administration, and activated charcoal (a medication used to treat an overdose). […]

• Immediate jeopardy, isolatedF689Jul 17, 2024

  Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent an accident for 1 of 3 residents reviewed for elopement, Resident ID #1. Findings are as follows: Record review of a facility policy titled Elopement states in part, .Elopement- leaving the facility without permission and/or notification to the facility .Assessment: An assessment will be completed within 24-hours of admission. 1. A determination of residents at risk will be made through the assessment process, observation and information received from other sources, such as family and medical records 2. A re-assessment will be completed for any resident who demonstrates any of the following . 3. A resident assess to be at risk. […]