Cedarburg Health Services

In the surveyor’s words

From the most serious findings on record at Cedarburg Health Services, in the surveyor’s own words.

• Actual harm, isolatedF686May 19, 2021

  Based on observation, record review, and interview, the facility did not thoroughly assess, document, and provide services consistent with professional standards of practice to prevent development or worsening of pressure injuries for 1 (R31) of 1 residents reviewed for pressure injuries. R31 developed a moisture associated skin damage area to the coccyx that progressed into a Stage 2 pressure injury. No documentation was found from 2/19/2020 until 7/15/2020 when it was assessed as a Stage 3 pressure injury with slough. […]

• No harm, potential for more than minimal, widespreadF812Aug 24, 2022

  Based on observation, staff interviews, and record review, the facility did not ensure food was stored, prepared, and served under sanitary conditions. Those practices had the potential to affect all 43 residents. Dietary Manager (DM)-H did not test sanitizing solution according to test strip manufacturer directions. The sanitizing solution did not dispense in water resulting in water rinse instead of sanitization of the food preparation sink. The facility did not maintain documentation of sanitizing solution testing. Dietary Cook (DC)-I did not wash hands after touching soiled items and prior to continuing with food preparation. Staff left scoops with handles in full contact with food in bulk food containers. […]

• No harm, potential for more than minimal, widespreadF880Aug 24, 2022

  Based on record review and interview, the facility did not establish and maintain an infection surveillance program designed to help prevent the development and transmission of disease and infection which had the potential to affect all 43 Residents (R) in the facility. Additionally, based on observation, record review and interview, the facility did not ensure implementation of infection control standards designed to prevent the transmission of disease and infection which had the potential to affect the 9 residents residing on the 300 unit of the facility. […]

• No harm, potential for more than minimal, widespreadF812May 19, 2021

  Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety which had the potential to affect 44 of 44 residents residing in the facility. The facility did not ensure frozen foods were stored properly to ensure freshness and prevent exposure. Findings Include: The facility policy, Food Storage: Cold Foods, dated 5/2014, revised 4/2018, indicated: All Time/Temperature Control for Safety foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. All foods will be stored, wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. […]

• No harm, potential for more than minimal, patternF692Apr 4, 2024

  Based on observation, staff and resident interview, and record review, the facility did not ensure fluids were provided on a consistent basis for 4 residents (R) (R3, R4, R5, and R6) of 4 sampled residents. R3, R4, R5 and R6 did not receive fresh drinking water on a consistent basis or in accordance with their nutritional assessment. Findings include: The facility's Hydration policy, with a review date of 7/26/22, indicates each resident should be offered sufficient fluids, to include water and other liquids, based on resident preferences and needs, to maintain proper hydration and health. This includes ensuring fluids are available and within reach. 1. […]