Inspection·August 11, 2023

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure that residents who require Dialysis received such services, consistent with professional standards of practice for 2 out of 3 residents (R1, R2) in a sample of 3. This failure resulted in R2 having to be sent to the emergency room and admitted with fluid overload. Residents Affected - Few Findings include: 1.) R2's Physician Order (PO) dated 07/13/23 documents Chronic combined systolic (congestive) and diastolic (congestive) heart failure, type 2 Diabetes Mellitus with diabetic chronic kidney disease, End stage renal disease, and dependence on renal dialysis. R2's PO dated 08/09/23 documents Dialysis - FYI - Dialysis Treatments 3 X Week at 2:45 PM At: (local dialysis center) Every M-W-F. R2's Care Plan dated 08/08/23 documents, Hemodialysis r/t End Stage renal failure. R2's MDS (Minimum Data Set) dated 07/20/23 documents that resident has no cognitive impairment. The MDS documents that R2 requires extensive assistance of one person for dressing, toilet use, and personal hygiene. The MDS documents that R2 is not steady, only able to stabilize with staff assistance. The MDS documents that R2 requires dialysis. R2's Nursing Note dated 08/07/23 at 10:22 AM documents Due to transportation issue, resident missed dialysis treatment on this shift, resident is her own POA and is aware, (V5) NP (Nurse Practitioner), is made aware, this nurse contacted (local dialysis center) and made aware. R2's Nursing Note dated 08/09/23 at 12:05 AM documents 11:17 pm: seen resident sitting on her bed, coughing nonstop, complained of shortness of breath and chest tightness. Legs were also swollen and painful as stated. R2's Nursing Note dated 08/09/23 at 12:16 AM documents 11:30 pm hooked on oxygen inhalation at 2 lpm (liters per minute) called POA (V6) but unable to reached her, instead this nurse left a voicemail. NP (V5) was notified thru (name of app). DON (Director of Nursing), Notified. 12 MN sent resident out to (local hospital), assisted by 2 EMTs (Emergency Medical Technician) via gurney. R2's Hospital Record dated 08/09/23 documents, Pt from (facility) via EMS (Emergency Medical System), for c/o (complaint of) shortness of breath and leg and abdominal swelling. Pt states the driver at the facility called in on Monday so none of the patients were able to go to dialysis. Breathing (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145571 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Health & Rehab Ctr One Perryman Street Lebanon, IL 62254 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)