Inspection Reports for Cedar Crossings

No deficiencies identified during this Complaint, Re-Licensure survey.

No deficiencies identified during this Complaint, Licensure Complaint, State Licensure survey.

No deficiencies identified during this Complaint, Licensure Complaint, State Licensure survey.

Multiple deficiencies identified including unsafe environment, notice requirements, quality of care, accident hazards, respiratory care, dialysis, staffing, nurse aide training, drug regimen review, medication storage, dental services, garbage disposal, infection control, and in-service training. Many deficiencies were corrected on revisit but some remained not corrected.

The facility was found deficient in multiple areas including maintaining a safe and homelike environment, providing timely transfer and bed hold notices, implementing care and treatment orders, ensuring safe smoking practices, respiratory care, dialysis medication administration, staffing adequacy, medication storage, infection control practices, and staff training. Several residents were affected by these deficiencies, with risks ranging from physical harm to lack of proper care and oversight.

The facility was found deficient in multiple areas including maintaining a safe and homelike environment, providing timely transfer and bed hold notifications, implementing care and treatment orders, ensuring safe smoking practices, respiratory care, dialysis medication administration, staffing adequacy, medication storage and labeling, dental care, infection control, and staff training. Several residents were at risk due to these deficiencies.

No deficiencies identified during this Complaint, Licensure Complaint, State Licensure survey.

Deficiencies identified related to reasonable accommodations, permitting residents to return, discharge planning, dental services, and initial comments. Some deficiencies were corrected on revisit but many remained not corrected.

The visit was complaint-related based on public complaints received on 6/28/24 regarding bed rails, 5/3/24 regarding discharge and belongings locked, and issues related to discharge meal provision. The complaints were substantiated as the facility failed to meet regulatory requirements in these areas.

The facility failed to provide bed rails needed for bed mobility for one resident, did not permit a resident to return after therapeutic leave exceeding bed-hold policy, and failed to provide meals for a resident discharged for extended transport. These deficiencies placed residents at risk of ADL decline, being unhoused, and unsafe discharge.

Deficiencies identified related to quality of care, including failure to provide timely optometry services and dental services. Some deficiencies were corrected on revisit but many remained not corrected.

The visit was complaint-related, focusing on the failure to provide timely optometry and dental services to Resident 5. The deficiencies were substantiated based on interviews, observations, and record reviews.

The facility failed to ensure timely optometry and dental appointments for Resident 5 after admission, despite multiple requests and documented care plans indicating the need for these services. Staff acknowledged the delays in scheduling these appointments.

Deficiencies identified including failure to re-evaluate elopement risks resulting in immediate jeopardy, failure to develop QAPI plan, and failure to conduct QAA committee meetings. Some deficiencies were corrected on revisit but many remained not corrected.

The complaint investigation was triggered by Resident 1's elopement on 6/12/24. The facility failed to properly assess and document elopement risks and interventions, leading to immediate jeopardy. Staff interviews revealed inconsistent communication and lack of alert status for the resident. The facility submitted an acceptable Immediate Jeopardy removal plan on 6/14/24, which included elopement risk assessments, care plan reviews, behavior monitoring, audits, and staff training.

The facility failed to adequately assess and update care plans for residents at risk of elopement, resulting in Resident 1's elopement and immediate jeopardy to resident safety. Additionally, the facility lacked a developed QAPI plan and failed to conduct quarterly QAA meetings with Medical Director involvement, placing residents at risk for suboptimal care.

Deficiencies identified related to respect and dignity, ADL care, and initial comments. Some deficiencies were corrected on revisit but many remained not corrected.

The complaint investigation found substantiated issues where Staff 10 yelled at Resident 2 causing anxiety, and care staff failed to assist Resident 3 with ADL and range of motion exercises due to lack of time.

The facility failed to ensure a resident was spoken to in a dignified manner, causing anxiety and fear, and failed to provide necessary assistance with activities of daily living and range of motion exercises for another resident, placing residents at risk for decreased self-worth and unmet care needs.

Deficiencies identified related to failure to provide appropriate supervision to prevent falls, incomplete medical records, call light system failures, and infection control. Some deficiencies were corrected on revisit but many remained not corrected.

The complaint investigation found substantiated failures including inadequate supervision leading to a resident fall with injury requiring hospitalization, incomplete medical records lacking fall assessments, and non-functional call lights for a resident, all placing residents at risk.

The facility failed to provide adequate supervision to prevent a resident fall that caused hospitalization, failed to complete a fall assessment after the fall, failed to maintain complete medical records, and failed to ensure call lights were in good working order for residents, placing them at risk for harm.

The investigation was complaint-driven, focusing on allegations of abuse and dignity violations involving residents #9, 27, 41, 227, and others. The facility was found to have delayed reporting abuse incidents to the state agency beyond required timeframes.

The facility failed to ensure residents were treated with dignity and respect, including incidents of verbal aggression and physical abuse between residents. Staff also failed to knock before entering a resident's room, compromising privacy. Additionally, the facility failed to timely report allegations of abuse to the state agency.

The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate informed consent for psychotropic medications, failure to accommodate resident needs and preferences, lack of timely abuse reporting, inaccurate resident assessments, inadequate bathing assistance, insufficient activities programming, failure to maintain vision and hearing services, lack of gradual dose reductions for psychotropic medications, unsecured medication carts, delayed dental care, failure to accommodate dietary choices, inadequate infection prevention practices, improper catheter care, and nonfunctional call light systems.

The facility failed to ensure the resident environment was free of potential fire hazards in one of the independent smoking areas, with discarded cigarette butts found in multiple locations without proper receptacles, placing residents at risk for injury and fire exposure.

The complaint investigation found substantiated issues including resident altercation resulting in abuse, lack of trauma-informed care planning, delayed call light responses, failure to perform INR testing as ordered, and delayed pain medication administration causing severe pain.

The facility was found to have failed to protect residents from abuse, failed to implement trauma-informed care plans, failed to respond timely to call lights, failed to conduct required INR testing, and failed to administer pain medication timely, resulting in resident distress and risk of harm.

The facility was found deficient in multiple areas including failure to follow physician medication orders, inadequate RN coverage, lack of nurse aide training and performance reviews, inaccurate nurse staffing postings, medication administration errors, unsecured medication and treatment carts, improper food storage and labeling, inaccurate clinical staff identification in records, and failure to clean injection sites prior to insulin administration.