The Gardens at Cedarwood

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF851Jun 17, 2025

  Based on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 2 2025 (January 1 -March 31) in accordance with the schedule specified by CMS. Findings include: Review of the facility's policy titled Payroll Based Journal, dated as revised January 2025, indicated but was not limited to: -It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS -The facility will submit direct care staffing… […]

• No harm, potential for more than minimal, widespreadF851May 8, 2024

  Based on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 1 2024 (October 1 - December 31) in accordance with the schedule specified by CMS. Findings include: Review of the CMS Payroll Based Journal (PBJ) Staffing Data Report, CASPER Report 1705D, indicated the facility failed to submit data for the quarter. During an interview on 5/8/24 at 7:44 A.M., the Nursing Staff Scheduler said she did not know who did the PBJ reporting. During an interview on 5/8/24 at 12:38 P.M., Consulting Staff #5 said in reviewing the data sent to him from the facility it appears the data from October 1-15 was missing. […]

• No harm, potential for more than minimal, widespreadF880May 8, 2024

  Based on observation, document review, policy review, and interviews, the facility failed to: 1. Maintain an infection prevention and control program with a complete system of surveillance to identify any trends of actual or potential infections within the facility; 2. For Resident #36, ensure staff wore personal protective equipment (PPE) as required for Enhanced Barrier Precautions (EBP); 3. For Resident #160, ensure EBP were implemented, and PPE was utilized when providing high contact resident care; and 4. […]

• No harm, potential for more than minimal, widespreadF812Jan 13, 2023

  Based on observation, interview, policy review, and document review, the facility failed to ensure the dish machine temperatures were monitored to ensure the machine was reaching temperatures to clean and sanitize the dishes as required per the manufacturer. Findings include: Review of the facility's policy titled Dish Machine, dated May 2020, indicated but was not limited to the following: - all staff will receive training consistent with manufacturer recommendation for dish machine use - high temp machines must reach water temperatures in accordance with manufacturer specifications for wash and rinse - dietary staff will record dish machine temperatures on a log after each meal service Review of the facility provided CMA Dish Machine owner's manual, Revision 2.08.A, undated, indicated… […]

• No harm, potential for more than minimal, widespreadF880Jan 13, 2023

  Based on observations, interviews, record review, and policy review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections in the facility. Specifically, the facility failed to: 1. Ensure that healthcare personnel performed hand hygiene, per the facility policy, while providing care to COVID-19 positive residents; 2. Ensure staff performed hand hygiene and appropriately wore personal protective equipment (PPE) prior to entering resident rooms as indicated by posted signs outside of resident rooms; 3. Follow infection control procedures while handling COVID-19 Binax tests; and 4. […]