Cedarbrook Residential Center

The facility failed to maintain clean and safe walls, ceilings, and floors. Specifically, a common bathroom had feces on the toilet seat and smeared on the wall, the shower stall contained a black substance in the grout, and dining room ceiling fans were coated in thick dust while in use during meals.

The facility failed to maintain clean and safe surfaces in common areas. Specifically, a shared bathroom contained feces on the toilet, walls, and shower grout, and dining room ceiling fans were coated in thick dust while in use during resident meals.

The facility failed to ensure at least one CPR-certified staff person was on the premises for each shift, as evidenced by 12 out of 13 sampled days in December 2023. Additionally, 14 of 20 direct care staff members lacked current documentation of CPR training completed within the last 24 months.

The facility failed to ensure at least one staff person on the premises for each shift had completed a CPR and choking management course within the last 24 months. Specifically, 14 out of 20 sampled direct care staff lacked current CPR documentation, and there were multiple instances between 12/19/23 and 12/31/23 where no CPR-certified staff were present in the building for several hours.

The facility failed to ensure necessary follow-up for a resident's medical needs. Specifically, after a physician ordered a referral to a gastroenterologist following an ER visit for altered mental status, the facility failed to confirm the appointment was scheduled, as the specialist's office had not received the referral.

The facility failed to provide adequate supervision for a resident with a history of aggressive behavior and substance abuse. Specifically, staff did not properly respond to the resident's verbalized threat to harm others following an escalation in behavior.

The facility failed to ensure medication administration was in accordance with physician orders for one resident. Specifically, oxycodone/APAP was not administered as prescribed due to the medication being unavailable at the facility, and there was no documentation that the pharmacy had been contacted to resolve the issue.

The facility failed to ensure medication administration was in accordance with physician orders for one resident. Specifically, the resident was without prescribed oxycodone/APAP from 08/31/19 to 09/03/19 because staff failed to request a refill and did not document any attempts to contact the pharmacy regarding the unavailable medication.