Cedarbrook Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Cedarbrook Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF697Nov 15, 2024

  Based on interview, and record review the facility failed to obtain physician ordered medication and ensure timely administration of pain medications for 1 (Resident #318) of 5 residents sampled for medication regimen review, causing ongoing severe pain to the resident. The findings included: Review of the clinical record for Resident #318 revealed a date of admission of 11/11/24. Diagnoses included chronic back pain due to spinal stenosis. On 11/13/24 at 10:47 a.m., in an interview Resident #318 said, I waited 20 hours to get a pain pill when I was admitted to the facility. I was miserable, in pain, and crying. The resident said she kept telling the nurse on duty to call the physician. Resident #318 said the nursing staff kept telling her the delivery would be here shortly. […]

• Actual harm, isolatedF689Mar 31, 2022

  Based on record review, review of the policies and procedures and staff interviews, the facility failed to ensure adequate supervision and failed to prevent avoidable accidents for 1 (Resident #1) of 3 residents reviewed who were identified as being at risk for falls. The failure to provide appropriate supervision resulted in Resident #1 sustaining a preventable fall with injury, requiring the resident's transfer to a higher level of care. The findings included: The facility's Fall Management Guidelines with an original date of 3/2022 specified fall risk is evaluated and documented upon admission and whenever there is a change in condition. […]

• No harm, potential for more than minimal, widespreadF812Jun 10, 2021

  Based on observation and staff interview, the facility failed to maintain the kitchen and nourishment rooms in a clean, safe, and sanitary manner that is in good repair by not having clean surfaces in food preparation and storage areas, and not maintaining the ice machine in a manner to prevent potential contamination. The findings included: 1. On 6/7/21 at 10:45 a.m., and 6/8/21 at 9:20 a.m., during tours of the kitchen, the following was observed: The entrance door was gouged with exposed wood on the bottom portion of the door inside the kitchen. There was a 6-inch by 2-inch hole in the wall on left side of the door. […]

• No harm, potential for more than minimal, widespreadF908Jun 10, 2021

  Based on observation, record review and interview the facility failed to maintain laundry room equipment, in safe operating condition. The findings included: The facts about home clothes dryer fires as outlined in the U.S. Fire Administration website at https://www.usfa.fema.gov/prevention/outreach/clothes_dryers.html notes Facts about home clothes dryer fires . Failure to clean the dryer (34 percent) is the leading cause of home clothes dryer fires. Review of the facility's laundry room cleaning policy dated 6/25/20 revealed, Dryer Cleaning and Dusting or Vacuuming . Clean lint screen every two hours . On 6/9/21 at 6:55 a.m., during a tour of the laundry room with the Director of Nursing (DON), Laundry Room Attendant Staff M was observed putting wet clothes in the dryers. […]

• No harm, potential for more than minimal, widespreadF921Jun 10, 2021

  Based on observation, resident, family, and staff interview, the facility failed to maintain a safe, sanitary, and comfortable environment, free from biological growth (bio growth) for residents, staff, and the public, by not having clean surfaces; not repairing damaged walls in resident rooms and bathrooms; and not storing resident personal care items in a sanitary manner. Not maintaining a sanitary environment has the potential for cross contamination and promotes bio growth. The findings included: 1. On 6/7/21 at 12:00 p.m., mold was identified in the South Wing nourishment room by the Life Safety surveyor. […]