Inspection Reports for Red Cedar Lodge

The investigation was initiated due to complaints alleging that Resident A eloped from the facility on 06/23/2025, with concerns about resident safety and supervision.

The investigation confirmed that Resident A and Resident B were able to exit the facility unsupervised, with Resident A found at a nearby hotel after being unaccounted for 10-15 minutes. The facility had broken fencing and unsecured gates allowing residents to leave the premises. Corrective action plans were submitted and accepted to address these violations.

Complaint received from Adult Protective Services alleging Resident A eloped from the facility. The complaint was substantiated with violations established related to resident elopement and facility safety.

The inspection was conducted as a special investigation initiated by a complaint received on 2025-03-04 regarding care concerns at Red Cedar Lodge.

The investigation found violations related to Resident A's fall and lack of proper incontinence care and checks, with documentation issues and lack of an organized program for fall alarms. Other allegations such as disrespectful treatment, medication errors, lack of assistance during mealtimes, missed showers, and trash removal were not substantiated.

The complaint alleged disrespectful treatment of residents, Resident A had a fall and was on the floor for over two hours, Resident A was not assisted with incontinence care nor checked on, Resident A did not receive a shower, medication was administered incorrectly, residents were not assisted during mealtimes, and trash was not taken out. Violations were substantiated only for the fall and incontinence care allegations.

The investigation was initiated due to a complaint alleging that call lights were not answered properly, incidents were not reported, and Resident A received incorrect medications at Red Cedar Lodge.

The investigation found no violation regarding call lights not being answered properly. However, violations were established for incidents not being reported, Resident A receiving incorrect medications, and deficiencies in employee training and competency evaluations. Additional findings included repeat violations related to service plan updates and staff training documentation.

Complaint received on 2024-10-14 alleging call lights were not answered properly, incidents were not reported, and Resident A received incorrect medications. Investigation substantiated violations related to incident reporting, medication errors, and staff training deficiencies, but not call light response.

The inspection was initiated due to an anonymous complaint alleging that Resident A was not tested timely for C-Diff at Red Cedar Lodge.

The investigation found that Resident A exhibited loose and watery stools as early as 09/30/2024, but the facility did not contact the physician for a stool sample order until 10/10/2024, resulting in a delay in testing and potential risk to the resident's health and safety. A violation was established for failure to act timely to ensure protection and safety.

The complaint alleged Resident A was not tested timely for C-Diff, with concerns documented both on paper and electronically. The complaint was substantiated as the violation was established.

The inspection was conducted in response to a complaint alleging that food in the memory care unit was not cooked properly.

The investigation found that the facility was unable to demonstrate that food was handled, stored, prepared, and transported safely for human consumption, specifically due to inconsistent and inadequate temperature monitoring of food served in the memory care unit.

The complaint alleged that food in memory care was not cooked. The violation was established. APS declined to investigate the allegations further.

The inspection was conducted in response to a complaint alleging insufficient staff in memory care on the second shift, specifically concerns that staff were serving meals which detracted from resident care and that sometimes only one caregiver was assigned to the floor after 7:00 pm.

The investigation confirmed that staffing levels in the memory care unit were inadequate to meet resident needs, with times when only two staff were present on second shift and one on third shift, insufficient to provide required care such as two-person assists and dining assistance. The facility's staffing protocol was found incapable of ensuring adequate care, constituting a violation of staffing regulations.

The complaint alleged insufficient staff in memory care on second shift, with staff expected to serve and plate dinner meals, reducing resident care. It was reported that after 7:00 pm, only one caregiver was assigned to the floor. The investigation substantiated the violation of insufficient staffing.

The inspection was conducted following a complaint received on 09/19/2024 alleging that Resident A had a fall on 09/13/2024 which was not reported to the family and resulted in broken teeth.

The investigation established violations including failure to provide appropriate medical attention after Resident A's fall, inadequate detail in Resident A's service plan regarding medication administration for agitation, and multiple instances of prescribed medications not administered as ordered. Additionally, the licensed health care professionals were not contacted regarding missed medications.

Complaint received from Adult Protective Services alleging Resident A had a fall on 09/13/2024 that was not reported to family and resulted in broken teeth. The complaint was substantiated with violations established.

The investigation was initiated due to a complaint from Adult Protective Services alleging that Resident B had multiple unreported falls at the facility.

The investigation found that Resident B had multiple falls on 08/19/2024, 09/21/2024, and 09/29/2024, with incomplete incident reporting and failure to complete required 72-hour monitoring and physician notifications for some falls. Bed bugs were found only in Resident B's room but were treated promptly. Additionally, Resident B's service plan was not updated to reflect current care needs, and the facility failed to maintain complete and accurate records of falls.

Complaint received from Adult Protective Services on 09/24/2024 alleging Resident B had multiple unreported falls. The complaint was substantiated with violations established related to unreported falls and incomplete care documentation. The allegation of bed bugs was not substantiated as a violation.

The investigation was initiated due to a complaint alleging neglect of Resident A at the facility and improper discharge of Resident A.

The investigation found no evidence to support neglect allegations but established violations related to improper discharge procedures, lack of detailed service plan for Resident A's agitation behaviors, invalid admission agreement due to inactive DPOA, and failure to administer prescribed medications as ordered.

Complaint alleged Resident A was neglected at the facility and improperly discharged. Neglect was not substantiated; improper discharge and additional violations were substantiated.

The inspection was conducted in response to a complaint alleging Resident D did not have a service plan until after admission, insufficient staffing, untrained employees, and a medication error involving Resident D.

Violations were established for Resident D not having a timely service plan, incomplete staff training documentation, multiple medication administration errors for Residents D and I, and misleading advertising of services provided. The allegation of insufficient staffing was not substantiated.

The complaint alleged Resident D did not have a service plan until after admission, the facility had insufficient staff, employees were not trained, and Resident D had a medication error resulting in a rash. Violations were substantiated for the service plan, employee training, and medication errors; insufficient staffing was not substantiated.

The document serves as a renewal notification for the Home for the Aged license of Red Cedar Lodge following an administrative review of licensing activity over the past year.

The administrative review revealed substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in license renewal.

The inspection was conducted in response to a complaint alleging insufficient staffing in the memory care unit, with concerns about residents needing skilled care and 1:1 assistance.

The investigation found that the facility had insufficient staff on multiple occasions, with only three staff members present despite residents requiring two-person assistance. The use of float staff potentially left other areas understaffed. The violation of staffing requirements was established.

Complaint received on 04/15/2024 alleged lack of staff in the memory care unit, with residents needing two-person assist and 1:1 assistance. The complaint was substantiated with a violation established.

The investigation was initiated due to a complaint alleging that Resident D did not have a service plan upon admission and that the facility made changes to Resident E and F's service plans without communicating these changes to the residents.

The investigation found that Resident D did not have a service plan developed with her upon admission, the admission agreement was signed 13 days late, and the facility failed to provide Resident D with a bed. Additionally, changes to Resident E's service plan were made but not communicated to the resident. Multiple violations of licensing rules were established.

Complaint received on 2023-11-17 alleging Resident D did not have a service plan upon admission. Investigation confirmed violations related to service plan development, communication of service plan changes, admission agreement timing, and provision of required furniture.

The inspection was conducted in response to a complaint alleging that memory care residents were at risk due to health and safety concerns with kitchen and dietary practices, including unsanitized dining tables, excessively hot coffee, and untrained caregivers in food service.

The investigation found violations related to food safety, including failure to take food temperatures before serving, caregivers not washing hands or wearing gloves while plating food, and food being placed on counters accessible to residents and visitors, posing contamination risks.

Complaint received on 2023-11-20 alleging memory care dining tables were not sanitized before meals, coffee served burning hot, and caregivers not trained in food service rules. Violation was established.

The inspection was conducted in response to a complaint alleging that Resident A and Resident B left the facility unsupervised, raising concerns about resident safety and supervision.

The investigation confirmed that Resident A and Resident B left the facility unsupervised on multiple occasions, indicating a lack of consistent supervision and protective measures. The facility failed to consistently complete door security checks and had deficiencies in staff training and employee competency evaluations.

The complaint alleged that Resident A and Resident B left the facility unsupervised. The investigation substantiated these allegations and found additional related deficiencies.

The inspection was conducted as a renewal licensing study to evaluate compliance with state regulations and determine if the facility's license should be renewed.

The facility was found to be in non-compliance with several rules including inadequate detail in residents' service plans, delayed tuberculosis screening for a new employee, unclear medication administration instructions, lack of supervision of prescription medications per service plans, and insufficient ventilation in the beauty shop and toilet rooms.

The inspection was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Red Cedar Lodge, a newly constructed assisted living facility.

The facility was found to be in substantial compliance with the home for the aged public health code and administrative rules. A temporary 6-month license with a maximum capacity of 155 beds was recommended for issuance.