Inspection Reports for
Cedar Lake Village

The inspection was triggered by multiple complaints (188813, 188995, 190314, 190488, 190578) concerning resident exploitation, service agreement deficiencies, resident safety, and other issues.

The facility was found deficient in multiple areas including resident exploitation, incomplete negotiated service agreements, failure to monitor outside service providers, resident safety neglect resulting in elopement, improper labeling of over-the-counter medications, incomplete documentation of incidents, inadequate emergency preparedness, and unsafe food handling and storage practices.

The administrator failed to protect a resident from neglect by ensuring certified staff assisted the resident up off the floor after a witnessed, non-injury fall. The facility reported a census of 52 residents with 16 in the memory care unit.

The report confirms that the deficiency identified under regulation 26-41-101 (f) (1) was corrected as of 10/23/2023. No other deficiencies or uncorrected issues are noted.

The facility failed to protect a resident from exploitation when a Certified Medication Aide took and shared a photo of the resident just after his death on social media, violating privacy policies. The facility responded with staff training, warnings, and policy reinforcement to prevent recurrence.

The resurvey included attached complaints #180747, #177552, and #173837. The investigation found substantiated issues related to neglect reporting, service agreements, food safety, infection control, and facility safety.

The facility failed to complete and submit timely investigations of alleged neglect, ensure negotiated service agreements reflected residents' needs, maintain safe food preparation and storage practices, comply with tuberculosis screening guidelines, and secure chemicals in locked areas to protect resident health and safety.

All previously cited deficiencies identified by regulation numbers 26-41-101 (f)(1), 26-41-205 (h), and 28-39-254 were corrected as of the revisit date.

The inspection included complaint investigations numbered 171588 and 169823. The complaints involved failure to implement fall interventions and failure to prevent resident elopement resulting in injury.

The facility failed to implement adequate interventions for residents with falls, resulting in injuries including a hip dislocation and facial laceration. Additionally, the facility failed to prevent a cognitively impaired resident from leaving the premises unsupervised in cold weather, resulting in injury. Medication storage and chemical safety deficiencies were also identified in secured memory care units.

The report confirms that the previously cited deficiency under regulation 26-41-101 (f)(1) was corrected as of the revisit date. No other deficiencies are listed as outstanding.

The survey included complaint investigations #154517 and #154539. The complaint was substantiated as neglect related to resident elopement and inadequate supervision.

The facility failed to ensure that a resident with a history of wandering and poor decision making was protected from neglect after eloping through an unlocked gate and being unaccounted for over two hours. The resident remained at risk for elopement due to lack of documented staff observation checks in the memory care unit.

The report confirms that the deficiency identified under regulation 26-41-204(i) was corrected as of 06/10/2019. No other deficiencies or findings are noted.

All previously cited deficiencies were corrected as of 04/30/2019, with no uncorrected deficiencies noted at the time of this revisit.

The administrator failed to ensure all health care services, including timely answering of call lights, were provided by qualified staff according to acceptable standards of practice. The call light response report showed numerous alerts with delayed responses, some exceeding 30 minutes and some never responded to.

Complaints #132608 and #134608 were investigated during the licensure resurvey.

The facility failed to timely report and investigate allegations of abuse, ensure negotiated service agreements included specific service descriptions and payment sources, provide health care services addressing residents' fall risks, ensure timely response to call lights, administer medications according to physician orders, properly label over-the-counter medications, and comply with tuberculosis screening guidelines for employees and residents.

The report confirms that the previously cited deficiency under regulation 26-41-204(d) was corrected as of the revisit date. No other deficiencies are listed as outstanding.

The facility failed to ensure proper reassessment of residents' functional capacity following significant changes, failed to provide or coordinate necessary health care services in accordance with functional capacity screenings and negotiated service agreements, and lacked documentation of licensed nurse responsibility in service agreements. Additionally, documentation of incidents, assessments, and follow-up actions for resident falls and illnesses was incomplete.

The report confirms that the deficiencies identified in the prior survey were corrected as of the revisit date.

The facility failed to record residents' functional capacity findings on screening forms including all required elements and definitions. Additionally, the licensed nurse did not properly delegate blood glucose monitoring procedures to certified medication aides and failed to document their competency.