Inspection Reports for
Red Cedar Lodge

Resident A eloped from the facility: established. Additional findings regarding broken fencing: established.

Two violations were established related to lack of an organized protection plan and broken exterior fencing allowing residents to exit unsupervised. A corrective action plan was submitted and accepted.

Residents treated disrespectfully: not established. Resident A had a fall: established. Resident A was not assisted with incontinence care nor checked on: established. Resident A did not receive a shower: not established. Medication administered incorrectly: not established. Residents not assisted during mealtimes: not established. Trash not taken out: not established.

Two rule violations were established related to Resident A's care: failure to ensure alarms were in good working condition and failure to provide adequate incontinence care and checks. Other allegations were not substantiated.

Call lights not answered properly: not established. Incidents not reported: established. Resident A received incorrect medications: established. Additional findings: service plan inaccuracies and employee training deficiencies — established.

Four violations were established related to incidents not reported, incorrect medications, service plan inaccuracies, and employee training deficiencies. One allegation about call lights not answered properly was not established.

Resident A was not tested timely for C-Diff: established. Additional findings: no.

One violation was established regarding the facility's failure to timely test Resident A for C-Diff, resulting in a corrective action plan requirement.

Resident A fell: established. Additional findings: service plan incomplete — established. Medication administration failures: established. Licensed health care professional not contacted: established.

Five violations were established related to Resident A's fall, inadequate medical attention, incomplete service plan for medication administration, and failure to administer prescribed medications and notify licensed health care professionals.

Resident B has had multiple unreported falls: established. Resident B has bed bugs: not established. Additional findings regarding incomplete records and service plan: established.

Three violations were established related to failure to complete required incident reports and monitoring after falls, incomplete medical records, and failure to update the service plan to reflect current care needs. The bed bug allegation was not substantiated.

Food in memory care is not cooked: established. Additional findings: not established.

One rule violation was established regarding food safety and temperature monitoring in the memory care unit.

Resident A neglected at the facility: not established. Resident A improperly discharged: established. Additional findings: multiple violations related to discharge notice, service plan, admission agreement, and medication administration — all established.

Five rule violations were established related to discharge notice, service plan, admission agreement, service plan development, and medication administration.

Resident D did not have a service plan until after admission: established. Facility has insufficient staff: not established. Employees are not trained: established. Resident D had medication error: established. Additional findings: independent living services offered in a licensed home for the aged and medication errors for Resident I — established.

Five violations were established related to resident service plans, staff training, medication administration, and program scope. One allegation of insufficient staff was not established.

The license was renewed following an administrative review that revealed substantial compliance with applicable rules.

Facility has insufficient staff: established. Additional findings: not established.

One rule violation was established regarding insufficient staffing in the memory care unit.

Resident D did not have a service plan upon admission: established. Facility made changes to Resident E and F service plans without communication: not established. Additional findings related to admission agreement, hospice service plan details, and furniture provision: established.

Four violations were established related to admission and retention of residents, including lack of service plan upon admission, missing admission agreement, inadequate service plan details for hospice care, and failure to provide an individual bed.

Resident A left the facility unsupervised: established. Additional findings: lack of supervision program, failure to notify department of changes, incomplete service plan, inadequate employee training and evaluation — all established.

Five rule violations were established related to supervision, notification of changes, service plan updates, and employee training and evaluation.

The facility is in substantial compliance with home for the aged public health code and administrative rules.