Inspection Reports for
The Cedars

The facility was found deficient in multiple areas including failure to report and investigate a missing Fentanyl patch for a resident, lack of a comprehensive hospice care plan for a resident, unsecured hazardous chemicals in linen closets, failure to provide a registered nurse as charge nurse for at least 8 consecutive hours daily, improper preparation of pureed diets, and unclean kitchen ovens across multiple households.

The Plan of Correction outlines multiple corrective actions to address deficiencies related to abuse reporting, medication management, hospice care planning, accident prevention, staffing, diet preparation, and food safety procedures. The facility commits to audits, staff education, policy revisions, and ongoing monitoring to ensure compliance and resident safety.

The Plan of Correction outlines multiple corrective actions to address deficiencies related to notification of physician for changes in resident status, blood sugar and medication monitoring, environmental cleanliness, fall prevention, medication storage and labeling, and ensuring residents are free of unnecessary drugs.

The facility failed to notify the physician of Resident 27's abnormal blood sugar levels, failed to provide effective housekeeping in the 803 house, failed to follow Resident 61's care plan by leaving him unattended in the bathroom resulting in falls, failed to provide adequate supervision to prevent accidents for Resident 61, failed to identify and report medication irregularities by the consulting pharmacist, failed to follow physician orders for blood sugar monitoring, and failed to discard expired medications in medication carts.

The Plan of Correction outlines corrective actions for multiple deficiencies including incomplete MDS assessments, inadequate individualized care plans, narcotic count reconciliation issues, pain management documentation, cross-contamination risks in food service, and QAPI policy improvements.

The visit included a complaint investigation KS#135332 as part of the recertification survey.

The facility was found not to be in substantial compliance with multiple deficiencies including inaccurate resident assessments, failure to revise care plans, improper pharmacy controlled substance procedures, failure to ensure drug regimens were free from unnecessary drugs, potential cross contamination in food service areas, and deficiencies in the Quality Assurance and Performance Improvement (QAPI) program.

The survey found a most serious deficiency at level 'F', widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, and the facility was found to be in substantial compliance effective 2018-12-17.

The facility identified deficiencies related to pain management, including assessment and follow-up by licensed nurses. The plan includes audits, electronic health record alerts, nursing education, and ongoing quality assurance monitoring.

The complaint investigation #130665 found that the facility did not document pain assessments for Resident #1 before and after pain medication administration, despite the resident frequently experiencing pain rated at 8 on a 0-10 scale. The resident died on 5/31/18.

The facility failed to provide proper pain assessment and management for one of five sampled residents, specifically Resident #1, who did not have documented pain assessments prior to and after administration of pain medication, placing the resident at risk for inadequate pain relief.

The survey found the most serious deficiency to be a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective July 5, 2018.

All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.

The inspection identified multiple deficiencies including failure to ensure licensed nurse assessments for resident self-administration of medications, lack of documentation of actual medication administration times, improper labeling of over-the-counter medications, improper storage of tuberculosis solution beyond recommended expiration, and failure to conduct quarterly reviews of the facility's emergency management plan with employees and residents.

The facility identified deficiencies related to care plan development and implementation, resident supervision, and accident hazard prevention. The plan outlines corrective actions including staff education, care plan reconciliation, safety walks, and ongoing monitoring to prevent recurrence.

Complaint investigation #125436 focused on the facility's failure to follow the care plan for Resident #1, who fell and sustained a hip fracture. The complaint was substantiated based on record review and staff interviews.

The facility failed to implement the care plan for Resident #1, who was at high risk for falls due to severe cognitive impairment and mobility issues. Staff left the resident alone in his/her room contrary to the care plan, resulting in a fall and fractured hip. The facility also failed to provide adequate supervision to prevent the accident.

The survey found the most serious deficiency to be F686, "G", CFR 483.25(d)(1)(2) at a level of actual harm that is not immediate jeopardy. The facility will not be given an opportunity to correct deficiencies before remedies are imposed, including denial of payment for new Medicare and Medicaid admissions effective March 3, 2018.

The plan outlines corrective actions for multiple deficiencies including resident rights notification, fall intervention participation, blood pressure monitoring, self-harm assessment, safety audits, medication diagnosis documentation, pharmacy reporting, and insulin pen labeling.

The inspection included a complaint investigation as indicated by the Health Resurvey and Complaint Investigation #118084.

The facility was found deficient in multiple areas including failure to provide Advance Beneficiary Notices for skilled services, failure to revise care plans with measurable interventions to prevent falls, failure to provide necessary care for elevated blood pressures, failure to maintain highest mental and psychosocial well-being for a resident with behavioral issues, failure to ensure pressure alarm functioning prior to a resident fall, failure to secure hazardous chemicals, failure to ensure drug regimens were free from unnecessary drugs, failure to follow up on pharmacist recommendations, and failure to label insulin pens with opening dates.

All previously identified deficiencies have been corrected as of 2017-09-11, according to the provider's plan of correction.

The visit was complaint-related due to an abuse allegation between a staff member and a resident. The allegation was substantiated, resulting in termination of the perpetrator and multiple corrective actions.

The facility confirmed the abuse allegation, terminated the perpetrator, and initiated staff education on abuse policies and reporting expectations. Multiple corrective actions were implemented including staff training, policy updates, resident interviews, and ongoing monitoring by the interdisciplinary team.

The complaint investigation #119096 was initiated due to allegations of verbal abuse of Resident #1 by staff, failure to notify the physician and responsible party timely, and failure to protect residents from abuse. The investigation substantiated the verbal abuse and identified multiple deficiencies in abuse reporting, investigation, and resident care.

The facility failed to notify the physician and responsible party timely after Resident #1 was verbally abused by staff, failed to provide an environment free from verbal abuse, failed to thoroughly investigate and report abuse allegations, failed to implement policies and procedures for abuse prevention and reporting, failed to provide medically-related social services following the abuse incident, failed to comprehensively assess Resident #1 after the incident, and failed to ensure nurse aides completed required in-service training.

The survey found that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety from July 5, 2017 through August 3, 2017. Deficiencies cited included F223"J", CFR 01-483.13(b), and F225"K" 01-483.25(c).

This Plan of Correction addresses a federal complaint dated 06/29/2017 regarding resident elopement.

The Quality Assurance Committee reviewed the deficiency related to a resident elopement attributed to poor decision-making and safety awareness. The facility implemented measures including updated elopement policies, staff education, resident photo and demographic tracking, and monitoring of wander guard transmitters to prevent future incidents.

The facility identified deficiencies related to resident elopement risk assessments, monitoring, and reporting. Corrective actions include implementing elopement assessments on admission and annually, use of wander guard transmitters, staff education on elopement identification and reporting, and updated policies and procedures.

The report confirms that the previously identified deficiencies under regulation 26-41-101 (f) (1) and 26-41-101 (f) (3) have been corrected as of the revisit date.

The complaint investigations #116975 and #103643 focused on the facility's failure to prevent Resident #1, who had severe cognitive impairment and was at risk for elopement, from leaving the facility unsupervised after a visitor let the resident out a secured door.

The facility failed to ensure adequate supervision and a safe environment for Resident #1, who eloped from the facility after a visitor let the resident out a secured door. The resident had severe cognitive impairment and was identified as an elopement risk, but staff did not prevent the resident from leaving unsupervised.

The complaint investigation found that Resident #1 and Resident #2, both cognitively impaired and independently mobile, exited the locked assisted living area without staff knowledge on multiple occasions. Resident #2's incidents were not investigated or reported to the state agency as required.

The facility failed to provide adequate supervision for two cognitively impaired, independently mobile residents who eloped from the facility without staff knowledge. Additionally, the facility failed to investigate and report incidents of elopement and wandering to the state agency as required.

Related to The Cedars complaint 12012016 regarding involuntary seclusion of a resident during dining.

The facility identified a resident who was involuntarily secluded by being seated at a bedside table away from peers during meals. The facility took corrective actions including relocating the resident's table, providing staff training on involuntary seclusion, updating policies, and ongoing monitoring through quality assurance meetings.

The investigation was based on complaints alleging involuntary seclusion of Resident #1. The facility was found to have placed the resident alone at a table against a wall in the hallway outside the dining room for all meals, which was confirmed by staff interviews and observations.

The facility failed to ensure Resident #1 was free from involuntary seclusion when staff placed the resident alone in a hallway outside the dining room, facing a wall during meals, which placed the resident at risk for involuntary seclusion.

All previously cited deficiencies identified by regulation numbers 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.15(c)(6), 483.25(l), 483.35(d)(1)-(2), and 483.35(i) were corrected as of the revisit date.

The Plan of Correction addresses multiple deficiencies including policy revisions and staff education related to abuse and neglect, resident council processes, PRN medication administration, pureed food preparation, and dining sanitation and safety. The facility outlines corrective actions and timelines to achieve compliance by April 6, 2016.

The visit was complaint-related as indicated by the Health Resurvey and complaint investigation #95476. The facility failed to report two unwitnessed falls requiring emergency evaluation, which was part of the complaint investigation.

The facility failed to report unwitnessed falls with injury to the state agency, failed to act upon resident grievances regarding snack availability and variety, failed to monitor medication effectiveness for certain residents, failed to prepare pureed foods in an attractive and palatable manner, and failed to store, prepare, and serve food under sanitary conditions.

The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective April 6, 2016.

The survey found the most serious deficiencies to be at an "F" level, indicating no harm with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The report documents that multiple deficiencies previously cited under various regulations were corrected by 02/20/2015, as verified during this revisit.

The plan addresses deficiencies related to cleaning, disposal of open and undated food, proper glove use, storage of clean dishes, and sanitizing thermometers. Corrective actions include cleaning completion, education sessions, installation of contact paper, ordering new shelves, and monitoring by the Certified Dietary Manager.

The revisit confirmed that the deficiency identified by regulation 28-39-158 (ID Prefix S0710) was corrected as of 02/18/2015. No other deficiencies or uncorrected issues were noted.

The facility failed to follow cleaning procedures to ensure all kitchen equipment, work areas, and dishware were clean, with multiple sanitation issues observed in both the main kitchen and assisted living kitchen.

The visit was triggered by a complaint investigation #82888 focusing on pressure ulcer prevention and other resident care concerns.

The facility was found deficient in multiple areas including failure to prevent pressure ulcers in a resident with decreased mobility, unsafe environment hazards for cognitively impaired residents, failure to monitor anticoagulant medication properly, improper food preparation and sanitation practices, and inadequate infection control procedures.

The survey found deficiencies at a level of actual harm that is not immediate jeopardy, with a history of noncompliance from a prior abbreviated survey. Enforcement remedies including denial of payment for new Medicare admissions were imposed effective February 28, 2015.

The report confirms that the deficiency identified under regulation 483.13(c) with ID prefix F0226 was corrected as of 12/19/2014.

Complaint Investigation #79175 involved allegations of abuse of Resident #1 by a staff member. The complaint was substantiated as the facility failed to protect the resident and properly report the incident.

The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents. Specifically, the facility did not implement the chain of command and failed to immediately report an incident of alleged abuse of Resident #1 by a staff member, allowing the staff member to complete their shift before suspension and termination.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The revisit confirmed that the previously reported deficiency with ID prefix F0323 related to regulation 483.25(h) was corrected on 2014-06-04.

This Plan of Correction is linked to a complaint investigation at The Cedars facility.

The plan outlines corrective actions including staff training on assisting with ambulation, individual staff discipline, development of procedures, competency assessments, and ongoing monitoring of staff compliance with care plans.

The complaint investigation #74222 found that the facility did not follow the care plan for Resident #1, who required standby assistance with ambulation. The resident fell on 4/2/14, sustaining a skull fracture and subdural hematoma. Staff were not positioned beside the resident as required, and the fall was witnessed by a Certified Medication Aide who was ahead of the resident. The resident was hospitalized and later admitted to hospice care.

The facility failed to provide appropriate supervision and assistance with ambulation for Resident #1, resulting in a fall that caused a skull fracture and subdural hematoma. The resident required assistance per care plan, but staff were not standing beside the resident during ambulation, leading to the injury.

The report confirms that deficiencies previously cited under regulations 483.25(d), 483.35(i), and 483.70(f) were corrected as of 11/25/2013.

The facility was found deficient in ensuring accessible call lights for residents, maintaining sanitary food preparation conditions, and providing a working resident call system in rooms and bathrooms.

All previously reported deficiencies were corrected as of 07/24/2012, with no uncorrected deficiencies noted at the time of this revisit.

The facility outlines corrective actions addressing multiple deficiencies including promoting resident dignity, skin assessment and care planning, diabetic assessment monitoring, catheter care, medication administration documentation, food service sanitation, pharmacist consultant report monitoring, and medication storage security. Education, monitoring, and quality assurance committee reviews are planned to ensure compliance.

The visit was a complaint investigation triggered by complaints #56411, #57575, and #56228.

The facility was found deficient in multiple areas including failure to maintain resident dignity during care, inadequate comprehensive care plans especially for skin issues, failure to provide necessary care to maintain residents' highest well-being, improper food handling and sanitation practices, failure to prevent urinary tract infections related to catheter care, unnecessary medication usage, failure to monitor medication side effects, and improper drug storage and security.

The Plan of Correction outlines corrective actions taken for deficiencies related to nursing assessments, call light system issues, dietary staff compliance with hair net policy, and maintenance of kitchen light fixtures. It includes timelines for completion and ongoing monitoring plans.

The plan addresses corrective actions taken for an affected resident involving suspension and termination of a nurse aide, staff inservice on abuse, neglect, and exploitation, policy revisions for immediate suspension upon accusations, and mandatory reporting training for all employees.

The Plan of Correction outlines specific corrective actions taken or planned for various deficiencies including pressure ulcer prevention, hazardous chemical storage, lab monitoring, pureed food preparation, food safety, and housekeeping practices.