Cedar Manor Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Mar 28, 2022

  Based on observation, clinical record review, staff interview, and hospital record review, the facility failed to hold a [MEDICATION(S)] ([MEDICATION(S)]) medication (blood thinner) according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #34 identified with an International Normalized Ratio (INR) lab value on 1/31/22 of 8.0 (therapeutic level 2-3). The facility failed to hold the [MEDICATION(S)] dose 2/1/22 and the recheck of the INR on 2/2/22 revealed a critical INR of 10.8. Resident #34 required transportation to the hospital. This failure resulted in Immediate Jeopardy to the health, and safety of the residents. The facility reported a census of 51 residents. Findings Include: 1. […]

• Actual harm, isolatedF684May 1, 2024

  Based on observation, record review, resident and staff interview and facility policy review, the facility failed to properly document assessments for two of eight residents reviewed (Residents #2 and #3). The facility failed to document Resident #2's weekly wound assessments. In addition, the facility failed to document the time Resident #3's seizure lasted and failed to document follow-up assessments. The facility reported a census of 51 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #2 required substantial/maximal staff assistance with toilet use and lower body dressing. […]

• Actual harm, isolatedF689May 1, 2024

  Based on observation, record review, resident, family and staff interview and review of facility policies, the facility failed to ensure the safety of 2 of 8 residents reviewed (Resident #1 and #5). Resident #5 fell while transferring with a Certified Nurse Aide (CNA). The fall resulted in 3 fractured ribs and a hemothorax (a condition where blood collects in the pleural space, the hollow area between lungs and rib cage). In addition, the facility failed to determine the cause of Resident #1's a facial bruise. The facility reported a census of 51 residents. Findings included: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. […]

• Actual harm, isolatedF760Dec 7, 2023

  Based on clinical record review, staff, resident, and Advanced Registered Nurse Practitioner (ARNP) interviews, and facility policy review, the facility failed to administer the correct medication to 1 out of 7 residents reviewed, when a resident received another resident's medication in error (Resident #1). The facility reported a census of 48 residents. Findings Include: The Minimum Data Set (MDS) Assessment for Resident #1, dated 10/25/23, listed diagnoses of Atrial Fibrillation (Afib), coronary artery disease (CAD), heart failure, and hypertension (high blood pressure). The MDS reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. […]

• Actual harm, isolatedF686Jun 29, 2023

  Based on clinical record review, observation, staff interviews and facility policy review the facility failed to implement interventions to prevent the development of a pressure ulcer for a resident identified at risk for the development of pressure ulcers and failed to perform hand hygiene during wound care for one out of one resident reviewed for pressure ulcers (Resident #8). The facility reported a census of 44 residents. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of Pressure Ulcers: Stage I - An intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]