Cedar River Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF678Aug 13, 2024

  Based on observation, interview, and record review the facility failed to ensure staff performed Cardiopulmonary Resuscitation (CPR- an emergency procedure consisting of chest compressions combined with giving breaths of air when the resident's heart stops and they stop breathing) to 1 of 3 residents (Resident 1) reviewed for unexpected death in the facility. The failure to ensure staff followed the facility's policy for CPR including staffs ability to accurately assess signs of irreversible death, immediately verify the Physician's Order (PO) for CPR status, immediately access the resident's POLST form (Physician Order for Life-Sustaining Treatment - a document the resident completes to declare their wishes for CPR or No CPR), initiate CPR, communicate effectively to the 911 operator,… […]

• Actual harm, isolatedF550Aug 13, 2024

  Based on interview and record review the facility failed to treat residents with dignity and respect and provide a dignified existence that promoted quality of life for 1 of 1 resident (Resident 2) reviewed for resident rights. The failure to have a process for staff to provide a comfortable environment for residents after the death of a roommate, placed residents at risk of feeling scared, unsafe, distressed, and have a diminished quality of life. Resident 2 was harmed, using the reasonable person concept, when their roommate (Resident 1) died and they were left in the same room with the deceased resident from 10:00 PM on [DATE] until 5:30 PM on [DATE], 19.5 hours. […]

• No harm, potential for more than minimal, widespreadF868Apr 21, 2025

  Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that included the required participants. This failure put residents at risk for unmet care needs due to ongoing non-compliance with federal regulations and detracted from the interdisciplinary effectiveness of the team. Findings included . <Facility Policy> According to a December 2024 facility Quality Assurance and Performance Improvement [QAPI] Committee policy, the committee would meet monthly and listed the staff to serve on the committee which included the: Administrator; Director of Nursing Services; Medical Director, and infection control representative. […]

• No harm, potential for more than minimal, widespreadF726Aug 13, 2024

  Based on interview and record review the facility failed to ensure nursing staff and nursing aide staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physician, mental and psychosocial well-being of each resident according to the facility assessment, resident-specific assessments and resident plans of care for 11 of 11 staff (Staff K, L, E, M, H - Certified Nursing Assistants and Staff C, N, G, D, O, P - Licensed Nurses) reviewed for competency. […]

• No harm, potential for more than minimal, patternF825Apr 20, 2026

  Based on observation, interview and record review, the facility failed to ensure specialized rehabilitative services were provided as determined by the physician's order and the residents' plan of care for 2 of 3 residents (Residents 1 & 2) reviewed for Occupational Therapy (OT) services. This failure placed residents at risk of not attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psychosocial well-being. Findings included . <Facility Assessment>Review of the updated February 2026 Facility Assessment showed the facility would conduct, document, and review their facility-wide assessment to consider their resident population and the resources needed to care for these residents. […]