Cedar Ridge Health & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Cedar Ridge Health & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 30, 2022

  There are two deficient practice statements. A. Based on observation, interview and record review the Facility failed to assess, monitor, implement interventions and provide supervision to prevent elopement for one of 22 residents (R65) reviewed for wandering/elopement risks in the sample of 55. This resulted in R65 eloping from the facility, being found by the local police department, and sent to hospital and diagnosed with acute hypothermia. The Immediate Jeopardy began on [DATE], when R65 eloped from the facility in his wheelchair. R65 was found 200 feet from the facility, out of his wheelchair, down a hill. The facility was unaware R65 was missing until they were notified by the police. R65 was taken to hospital where he was diagnosed with acute hypothermia. […]

• Actual harm, isolatedF697Jan 30, 2025

  Based on interview, observation, and record review the facility failed to provide effective pain management for 1 (R10) out of 1 resident reviewed for pain in the sample of 44. This failure resulted in R10 experiencing ongoing pain during peri-care as evidence by visual and audible reports of pain expressed. Findings include: R10 was readmitted to the facility on [DATE] from the hospital with diagnosis of, in part, surgical aftercare on the digestive system, calculus of bile duct with cholecystitis, biliary acute pancreatitis, acute and chronic respiratory failure, and transient cerebral ischemic attack. […]

• Actual harm, isolatedF698Aug 11, 2023

  Based on interview, observation, and record review the facility failed to ensure that residents who require Dialysis received such services, consistent with professional standards of practice for 2 out of 3 residents (R1, R2) in a sample of 3. This failure resulted in R2 having to be sent to the emergency room and admitted with fluid overload. Findings include: 1.) R2's Physician Order (PO) dated 07/13/23 documents Chronic combined systolic (congestive) and diastolic (congestive) heart failure, type 2 Diabetes Mellitus with diabetic chronic kidney disease, End stage renal disease, and dependence on renal dialysis. R2's PO dated 08/09/23 documents Dialysis - FYI - Dialysis Treatments 3 X Week at 2:45 PM At: (local dialysis center) Every M-W-F. […]

• Actual harm, isolatedF684Jun 20, 2023

  Based on interview and record review, the facility failed to have staff to monitor resident after returning from the hospital for one of three residents (R2), reviewed for monitoring in the sample of 17. This failure resulted in R2 being sent back out to the hospital after being found unresponsive with no heartbeat, spontaneous respirations, and blood pressure. Findings Include: R2's Nurse's Transfer Note dated [DATE] documents Sent To: a (local hospital) Date: [DATE] 14:45 (2:45 PM) the reason(s) for Transfer: Abnormal Pulse Oximetry (low oxygen saturation), MD notified of transfer. R2's Nurses Note dated [DATE] documents 3:53 AM resident (R2) came back to the facility. […]

• Actual harm, isolatedF690May 15, 2023

  Based on observation, interview and record review, the facility failed to provide timely and complete incontinent care to prevent urinary tract infections (UTI) and provide timely treatment for residents with UTIs for 3 of 4 residents (R1, R3, and R4) reviewed for incontinent care and UTIs in the sample of 10. This failure resulted in R1 developing a UTI which was not treated for 14 days causing pain. Findings include: 1. On 5/5/23 at 9:40 AM R1 stated, I am wet, and she is going to change me. My diaper doesn't hold all the pee because they don't change me often enough. R1 stated V4 (Certified Nursing Assistant/CNA) was working last night and was the one who changed her diaper last. […]