Frederick Living - Cedarwood

In the surveyor’s words

From the most serious findings on record at Frederick Living - Cedarwood, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF676Aug 13, 2026

  Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide appropriate treatment and services to maintain or improve the ability to carry out certain activities of daily living that included mobility and walking for one of five sampled residents who had limitations in carrying out activities of daily living. (Resident 8)Findings include: Clinical record review revealed that Resident 8 had diagnoses that included Parkinson's disease, dementia, restless leg syndrome, and an abnormal gait. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had some memory impairment and had limitations in range of motion in both upper and lower extremities. […]

• No harm, potential for more than minimal, isolatedF684Oct 26, 2023

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician's order was implemented for three of 12 sampled residents. (Residents 22, 23, 30) Findings include: Clinical record review revealed that the physician directed staff to administer the following bowel protocol for Residents 22, 23, and 30: staff was to administer prune juice on day shift (7:00 a.m. to 3:00 p.m.) if the resident had no bowel movement (BM) in 72 hours. If prune juice was ineffective, staff was to administer milk of magnesia 24 hours later on evening shift (3:00 p.m. to 11:00 p.m.). If milk of magnesia was ineffective, a bisacodyl suppository was to be administered on night shift (11:00 p.m. to 7:00 a.m.). […]

• No harm, potential for more than minimal, isolatedF550Nov 4, 2021

  Based on a confidential group interview, it was determined that the facility failed to administer vaccinations in a dignified manner to two of four residents at resident council. Findings include: During a confidential group interview on November 3, 2021, at 10:30 a.m., two residents stated that during the month of October 2021, the pharmacist entered the facility during lunch to administer the booster vaccine to all the residents. The residents stated, We felt like we were rounded up like cattle during our meal time to receive a booster vaccine. The residents stated that there was no privacy provided and that they were afraid to express their feelings about the situation. The residents felt the situation could have been handled in a more dignified manner. 28. […]

• No harm, potential for more than minimal, isolatedF689Nov 4, 2021

  Based on clinical record review, observation and staff interview, it was determined that the facility failed to ensure that safety interventions were implemented and in place for one of 16 sampled residents. (Resident 42) Findings include: Clinical record review revealed that Resident 42 had diagnoses that included abnormalities of gait and mobility and history of falling. The current care plan identified that the resident was at risk to fall related to gait balance problems, poor safety awareness, history of falls, anxiety, and wandering. On September 6, 2021, Resident 42 fell in the dining room. […]

• No harm, potential for more than minimal, isolatedF697Nov 4, 2021

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure pain management included the attempt to provide non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain mediation prescribed on an as needed basis for three of 16 sampled residents. (Residents 22, 28, 43) Findings include: Clinical record review revealed that Resident 22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . […]