The Cedars

In the surveyor’s words

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

• Immediate jeopardy, isolatedF726May 5, 2022

  The facility identified a census of 50 residents. The sample included three residents reviewed for quality of life/quality of care. Based on record review and interview, the facility failed to ensure licensed nursing staff possessed the skills and knowledge necessary to act immediately upon changes in Resident (R) 1's health status when Licensed Nurse (LN) G failed to ensure R1's physician received the notification regarding R1's respiratory difficulty and changes in R1's mentation. On 04/03/22 at 05:15 AM LN G documented R1 had decreased oxygen saturation at 90 percent (%) (the amount of oxygen present in blood, normal is 95 to 100 %) and confusion. […]

• Actual harm, isolatedF689Jun 27, 2023

  The facility identified a census of 38 residents with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to use safe methods when transferring and ambulating Resident (R) 1, placing her at risk for falling, injury, and pain. On 06/04/23 at 06:45 AM, Certified Medication Aide (CMA) R ambulated R1 from her room to the scale, to weigh R1. CMA R did not place a gait belt on R1. CMA R got R1 close to the scale and then CMA R turned her back to R1 to turn the scale on. During this time, R1 reached for her phone in the basket of her walker and in doing so, lost balance and fell to the floor on her left side. She landed on her left hip/upper thigh. Staff assessed R1 for injury and noted no deformity or bruising. […]

• Actual harm, isolatedF689Apr 5, 2021

  The facility had a census of 63 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to ensure a safe and hazard free environment for one of three sampled residents. Resident (R) 1, a severely cognitively impaired resident, spilled a cup of hot coffee on herself after served by staff and left the resident unattended. The hot coffee caused second degree [CONDITION(S)] (when the first layer and some of the second layer of skin are burned) to the resident's left breast, abdomen, and bilateral thighs, and she required treatment at the emergency room . […]

• No harm, potential for more than minimal, widespreadF812Mar 11, 2024

  The facility had a census of 37 residents. The facility had one main kitchen and three kitchenettes. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 37 residents who received their meals from the facility's kitchens when staff stored unlabeled, undated food in the refrigerators. Staff did not sanitize the thermometer between food items when checking food temperatures and failed to ensure clean and sanitary preparation areas. […]

• No harm, potential for more than minimal, widespreadF851Mar 11, 2024

  The facility had a census of 37 residents. Based on observation, record review, and interview, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (YR) 2023 Quarter 2 indicated the facility did not have a Registered Nurse (RN) on 5 dates, FY 2023 Quarter 3 indicated no RN for on 91 dates and FY 2023 Quarter 4 for 26 dates. […]