Cedar View Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF686Jul 30, 2021

  Based on observation, record review and interview the facility failed to 1) prevent the development of a pressure ulcer after a contracture developed and 2) appropriately assess a pressure ulcer according to facility policy for 2 Residents (#23 and #57) out of a total sample of 25 residents. Findings include: The facility policy titled Pressure Ulcers/Skin Breakdown--Clinical Protocol, undated, indicated the following: * The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcers. […]

• Actual harm, isolatedF688Jul 30, 2021

  Based on observation, record review and interview, the facility failed to prevent a decline in range of motion (ROM) resulting in new bilateral hand and wrist contractures for one Resident (#23) out of a total 25 sampled. Findings include: The facility policy titled Resident Mobility and Range of Motion, undated, indicated the following: *Residents will not experience an avoidable reduction in range of motion (ROM). *Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in ROM. * Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility and unless reduction in mobility is unavoidable. […]

• Actual harm, isolatedF684Apr 7, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she received care and services consistent with professional standards of practice, when after obtaining a physicians order on 12/24/20 to collect a urine sample for a suspected urinary tract infection (UTI), which included nursing could collect the urine sample via straight catheter, the urine sample was not obtained until three days later, on 12/27/20, the same day Resident #1 was transferred and admitted to the Hospital with [CONDITION(S)] (a life threatening complication of an infection). […]

• Actual harm, isolatedF694Apr 7, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who require fluids via intravenous (IV) infusion for hydration, the Facility failed to ensure nursing followed professional standards of practice for maintaining and documenting the use of an IV, when there was no documentation to support that after his/her initial IV was placed, that the site or location of his/her IV site was changed by nursing, and there was no documentation, including a physician's order, to indicate why the IV was discontinued on 12/25/20 and not changed, as ordered. […]

• No harm, potential for more than minimal, widespreadF812Jul 30, 2021

  Based on observation, record review, and interview, the facility failed to maintain sanitation through 1. appropriate dish machine function and sanitation and 2. proper glove use. Findings include: 1. The following are general recommendations according to the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code: *High Temperature Dishwasher (heat sanitization): o Wash - 150-165 degrees Fahrenheit; o Final Rinse - 180 degrees Fahrenheit; (160 degrees F at the rack level/dish surface reflects 180 degrees F at the manifold, which is the area just before the final rinse nozzle where the temperature of the dish machine is measured); or 165 degrees F for a stationary rack, single temperature machine. […]