Cedar Mountain House

The facility failed to administer medications as ordered by a licensed practitioner for two residents. Specifically, a medication aide failed to provide budesonide for Resident #7 due to lack of stock and failed to provide a vitamin and shortness of breath medication for Resident #2.

The facility failed to administer medications as ordered by a licensed practitioner for two residents. Specifically, one resident did not receive budesonide for shortness of breath due to a lack of available medication, and another resident did not receive a vitamin for macular degeneration. This resulted in a medication error rate of 4% during the surveyed period.

The facility failed to ensure that staff provide personal care to residents according to their individual care plans. Staff must attend to all personal care needs that residents may be unable to manage independently.

The facility failed to provide personal care according to the resident's care plan for one resident regarding limited assistance with bathing. Although the resident's care plan required assistance, the resident was documented as showering independently, and staff did not remain present to prevent falls. This lack of supervision left a high fall-risk resident at risk of injury during bathing.

The facility failed to ensure that at least one staff person on the premises at all times, specifically during night shifts, had completed a CPR and choking management course within the last 24 months. Record reviews and staff schedules from November 2023 showed 9 out of 14 night shifts lacked CPR-certified personnel.

The facility failed to ensure that at least one staff person on the premises was CPR certified at all times. Specifically, for 9 of 14 shifts between 11/01/23 and 11/14/23, there were no staff members on the night shift who had completed a CPR course within the last 24 months.

The facility failed to ensure all new residents received services in a timely manner. Additionally, they failed to ensure all new residents were assessed to determine if they required services from an appropriate agency.

The facility failed to review orders for resident refusals, parameters, and drug medication updates and contact the physician as needed.

The facility failed to ensure that all residents with dietary needs were provided with the appropriate diet orders and that all dietary changes were documented.

The facility failed to ensure that dietary changes were reviewed at least 4 times within a month to ensure medications and treatments were documented correctly.

The facility failed to ensure that all residents with dietary needs received a physician's order. They also failed to review orders at least 5 days after the physician's order to ensure residents receive dietary changes.

The facility failed to ensure that any physician's order regarding issues with a resident's diet was reported to the physician within 24 hours.

The facility failed to ensure that the Heat Lamp kept on-site was used to monitor compliance and infection control, as the Heat Lamp department was representative of a state that was not in compliance.

The facility failed to ensure that all new residents were assessed to determine if they required services from an appropriate agency. They also failed to review orders for resident refusals, parameters, and drug medication updates.

The facility failed to ensure that any staff member found not following policies and procedures was disciplined, including termination.

The facility failed to ensure that all medication carts and drugs available in the facility were properly maintained to ensure availability. Additionally, they failed to review dietary orders to ensure residents receive medications timely.

The facility failed to ensure that physician contact was made as necessary according to any parameters ordered for the resident.

The facility failed to ensure that all medications and treatments appear on the 24-hour's as ordered by physician. They also failed to ensure that all medications and treatments are documented correctly.

The facility failed to ensure therapeutic diets were served as ordered for a resident requiring a mechanical soft diet with pureed vegetables. Observations and interviews revealed the resident was served regular vegetables instead of pureed, and staff were unaware of the specific physician's order for pureed vegetables.