The Cedars Care Home

Based on interview with Administrator and record review the facility neglected to have at least one staff member who has CPR and 1st Aid training on duty at all times. Facility has 5 out of 5 caregivers that work at the facility without a valid CPR certificate which poses an immediate health, safety risk to residents in care.

Based on record review and interviews conducted with Administrator, the facility did not comply with the section cited above per regulation, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review & interview with Administrator, the licensee did not comply with the section cited above in 3 out of 7 residents (R1-R3) did not have current, updated medical assessments (602)'s which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's observation & record review, the licensee did not comply with the section cited above in 5 out of 5 staff (S1-S5) did not have current/updated required trainings (any for 2023) which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's observation & interview with Administrator, the licensee did not comply with the section cited above in 3 out of 3 residents bathroom water faucets measured 130.8 degrees F & 135.5 degrees F, which are not within the allowable ranges of 105 to 120 degrees F. which poses/posed an immediate health, safety or personal rights risk to persons in care.

Based on LPA's interview with Administrator and record review, the licensee did not comply with the section cited above in 3 out of 7 residents (R1, R2, & R3) did not have current updated reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview with Administrator &record review, the licensee did not comply with the section cited above in 5 out of 5 staff (S1-S5) did not have required training in their files which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and interview, the facility did not comply with the section cited above in 1 out of 8 bedrooms had storage in room and 2 out of 5 restrooms also had supplies, laundry, toilet seat in tub, walker in tub and other supplies (photos taken) which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the facility did not comply with the section cited above in 1 out of 1 alcohol bottles were accessible to residents in care. LPA observed alcohol in refrigerator by resident rooms. Alcohol was unlocked and accesible to residents which poses an immediate health, safety or personal rights risk to persons in care.

§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidence by: This requirement was not met as evidence by: Based on the Department’s investigation R1 was the victim of elder abuse by staff which poses an immediate risk to the health, safety and Personal Rights of residents in care.

1569.269 Enumerated rights; severability (a)Residents of residential care facilities for the elderly shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on LPA observation, interview and record review, R1’s telephone calls and visitations were restricted. This is an immediate risk to the health, safety and rights of the residents in care.

87211(a)(1)(D) Reporting Requirements. (a) Each licensee shall furnish to the licensing agency...: (1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of ....(D) Any incident which threatens the welfare, safety or health of any resident....This requirement has not been met as evidenced by: Based on records review, interviews R1 had two incidents occurring on or around 7/4/2021 & incidents were not reported within regulatory timeframes and one incident that was not reported to CCL. R2 had an incident that was not reported within regulatory timeframes. This poses a potential risk to the health & safety of resident in care.

87468.1 (a)(6) Personal Rights of Residents in All Facilities (a) Residents in all RCFEy shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by: Based on LPA observation, interview and record review R1’s movement was restricted at the facility. This poses an immediate risk to the health safety and personal rights of residents in care.

87465(g) Incidental Medical and Dental Care Services - 9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident’s health, including an apparent life-threatening medical crisis. This requirement is not met as evidenced by: Based on LPA observation, interviews and record review it was determined that staff did not seek medical attention in a timely manner for R1 and R2 which poses an immediate risk to the health, safety, and personal rights to residents in care.