Cedars Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 13, 2022

  Based on staff interview, clinical record review, facility document review and complaint investigation, the facility staff failed, for one of three residents in the survey sample (Resident #2), to provide a safe transfer with a mechanical lift resulting in a leg fracture and failed to prevent a fall during provision of personal care resulting in a femur fracture and scalp laceration. The findings include: Resident #2 was admitted to the facility with diagnoses that included [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], post traumatic seizures, [CONDITION(S)], anxiety and depression. […]

• No harm, potential for more than minimal, widespreadF812Sep 29, 2021

  Based on observation, facility document review, staff interview and complaint investigation, the facility staff failed to store, prepare and serve food in a sanitary manner in the main kitchen, serving all residents in the facility. The findings include: On 9/28/21 at 10:15 a.m., accompanied by the dietary manager (other staff #2), the kitchen and food storage areas were inspected. The dishwasher, identified by the dietary manager as chemical/low temperature machine was running upon entrance to the kitchen. The dishwasher gauges for pre-wash temperature and wash temperature were not working. The grout on the tiled wall behind the dishwasher was black and stained. Crumbs, lint, dried debris were observed on top of the panel over the dishwasher gauges. […]

• No harm, potential for more than minimal, patternF658Feb 27, 2025

  Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of practice with regards to medication administration for three residents (Resident #2- R2, Resident #4-R4, and Resident #5 -R5), in a survey sample of six residents. The findings included: 1. For Resident #2, the facility staff failed to administer medications timely. On 2/26/25 at 11:25 a.m., an interview was conducted with R2 in her room. R2 reported, I haven't gotten my morning medications yet. When asked what time they are scheduled, R2 reported, 8 a.m. When asked how often this happens, R2 said, A lot. When asked if she knows why, R2 said, No, I don't know why. […]

• No harm, potential for more than minimal, patternF684Feb 27, 2025

  Based on resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for one resident (Resident #2- R2) in the survey sample of six residents. The findings include: For R2, the facility staff failed to accurately transcribe a physician order, resulting in multiple occurrences of medications being administered at the wrong dose. On 2/26/25 at 11:25 a.m., R2 was visited in her room. When asked about medications, R2 reported she had difficulty getting her medications timely. On 2/26/25 and 2/27/25, a clinical record review was conducted of R2's chart. According to a progress note dated 2/10/25, from a neurologist that R2 saw that day, the note read in part, . Assessment/Plan: . […]

• No harm, potential for more than minimal, patternF755Feb 27, 2025

  Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure medications were available for administration for four residents (Resident #4-R4, Resident #5-R5, Resident #1-R1, and Resident #20-R20) in a survey sample of 6 residents. The findings included: 1. For R1, the facility staff failed to have Gabapentin available for administration in accordance with physician orders. On 2/26/25 at 11:15 a.m., an interview was conducted with R1. During the interview, R1 said, This is my 3rd day without gabapentin. I think it has to do with agency nurses. […]