Cedarcrest Care Center

Based on record review and interview, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for 1 (#51) of 9 sampled residents who were reviewed for baseline care plans. The DON identified 60 residents resided in the facility. Findings: A significant change assessment, dated 05/14/25, showed Resident #51 had a diagnosis of diabetes mellitus, had a BIMS score of 11 which indicated the resident was moderately impaired in cognition for daily decision making, and had an original admission date of 04/04/24. Review of the electronic clinical record did not show a baseline care plan was developed for Resident #51. On 05/22/25 at 9:12 a.m., the resident care coordinator stated the nurses had not been completing baseline care plans. The resident care coordinator stated they had completed some baseline care plans for recent admissions. They stated there was not a baseline care plan developed for Resident #51. On 05/22/25 at 2:52 p.m., the DON stated they had not been monitoring to ensure baseline care plans had been completed within 48 hours of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed to include a restorative plan for 1 (#51) of 3 sampled residents whose care plans were reviewed. The DON identified 60 residents resided in the facility. Findings: On 05/22/25 at 8:53 a.m., Resident #51 was observed ambulating from the dining room using a walker. A physical therapy summary document showed skilled services were provided to Resident #51 from 03/03/25 to 04/01/25. A significant change MDS, dated [DATE], showed the resident had a BIMS score of 12 which indicated moderate cognitive impairment for daily decision making, and had diagnoses which included macular degeneration and dementia. A restorative progress note, dated 05/19/25 at 2:13 p.m., read in part, All walk program with assuasive device as tolerated Encouraged to walk in hallway more and resident has been doing some LE [left extremity] exercises at rail as tolerated and allowed has been refusing at times will continue to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure enteral feeding were labeled for 1 (#37) of 2 sampled residents who were reviewed for enteral tube feedings. The DON identified two residents had enteral tube feedings. Findings: On 05/21/25 at 11:29 a.m., Resident #51 was observed in bed. A feeding pump was observed with a bag of tan liquid and a bag of clear liquid infusing at 50 mls per hour. The bags were not observed to be labeled or dated. On 05/21/25 at 4:41 p.m., Resident #51 was observed to be assisted from the dining area to their room. The feeding pump was observed with a bag of tan liquid and a bag of clear liquid infusing at 50 mls per hour. The bags were not observed to be labeled or dated. On 05/22/25 at 8:05 a.m., Resident #51 was observed in bed. The feeding pump was observed with a bag of tan liquid and a bag of clear liquid infusing at 50 mls per hour. The bags were not observed to be labeled or dated. A feeding syringe, in a bag, dated 05/19/25, was observed hanging on the enteral feeding pump. On 05/22/25 at 9:28 a.m., LPN #1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a clinical rationale from the physician was provided on a gradual dose reduction request for an antianxiety medication for 1 (#29) of 5 sampled residents who were reviewed for unnecessary medications. The DON identified eight residents were ordered an antianxiety medication. Findings: A Medication Regimen Review, dated 03/19/25, read in part, lorazepam [a benzodiazepine] 0.5mg bid [twice daily] lorazepam 0.5mg q 4 hours prn [as needed].Do you feel that this resident is stable enough to tolerate a trial reduction of either of the above medications at this time? If not, please provide your clinical rationale. The medication regimen review showed the physician had documented continue on the form. The medication regimen review did not show a documented clinical rationale to continue the medication. A quarterly assessment, dated 04/03/25, showed the resident had a BIMS score of 03 which indicated the resident was severely impaired in cognition for daily decision making, had a diagnosis of Alzheimer's disease, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to thoroughly investigate an injury of unknown origin for 1 (#4) of 4 sampled residents reviewed for abuse. The assistant director of nursing reported 63 residents resided in the facility. Findings: An undated Abuse Prevention Policy and Procedure policy, read in part, an immediate investigation will be initiated into any allegation of abuse, neglect or misappropriation of resident property .1. The Director of Nursing/Wellness Director or designee will complete the investigation process and document the steps taken and the information obtained. Resident #4 had diagnoses which included Alzheimer's disease, dementia, anxiety, and delusional disorders. A quarterly minimum data set assessment, dated 12/22/24, showed the resident's brief interview for mental status score was 99, which indicated the resident could not participate in the interview. On 03/03/25 at 10:43 a.m., LPN #1 stated in October the nurse aides found Resident #4 with their top lip discolored and with bite marks underneath. LPN #1 stated, We don't know how it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide an environment free of abuse. The facility daily census report identified 24 residents on the secured unit and 62 total residents. Findings: 1. Resident #1 had diagnoses which included Alzheimer's dementia. A behavior note, dated 01/20/24, documented Resident #1 was observed to push another resident to the floor. When asked why, Resident #1 replied that they deserved it. A behavior note, dated 01/27/24, documented Resident #1 pushed another resident who had wandered into Resident #1's room. When asked why, Resident #1 replied that it was the only way they would get the other resident out of their room. An incident note, dated 02/07/24, documented in part, .It was reported to this nurse, this res went into another res room last eve and had an altercation with another res .this res has a habit of going into the first room on left as [their] room is in the same place on a different hall .hard to redirect at times . A behavior note, dated 03/01/24, documented Resident #1 threw water on another resident and swung their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to: a. provide an environment free from resident to resident abuse; and b. ensure staff accused of abuse did not have access to facility residents until the allegation was thoroughly investigated for one (Resident #3) of four residents reviewed for abuse investigation. The facility roster identified 62 residents. Findings: 1. Resident #1 had diagnoses which included Alzheimer's dementia. A behavior note, dated 01/20/24, documented Resident #1 was observed to push another resident to the floor. When asked why, Resident #1 replied that they deserved it. A behavior note, dated 01/27/24, documented Resident #1 pushed another resident who had wandered into Resident #1's room. When asked why, Resident #1 replied that it was the only way they would get the other resident out of their room. An incident note, dated 02/07/24, documented in part, .It was reported to this nurse, this res went into another res room last eve and had an altercation with another res .this res has a habit of going into the first room on left as [their] room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to update care plans for two (#1 and #3) of four resident whose clinical records were reviewed for abuse. The facility daily census report identified 24 residents on the secured unit and 62 total residents. Findings: 1. Resident #1 had diagnoses which included Alzheimer's dementia. A progress note, dated 08/09/24 at 8:01 p.m., documented in part, .This nurse heard screaming from residents room. Upon arrival resident was seen choking another resident [Resident #2], laying in a supine position in room-mates bed. This nurse was able to separate aggressive resident and defuse situation. Resident was upset that another resident was in [their] room-mates bed . An incident note, dated 08/09/24, documented in part, .This nurse heard screaming from another residents room. Upon arrival [Resident #2] was in another residents bed, laying in a supine position being choked by [Resident #1]. This nurse was able to pull resident to safety. [Resident #2] was purple colored w/ unsteady gait, and scratches on (L) [left] side of face and neck .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to implement their abuse policy related to the reporting of an allegation of abuse within two hours of staff knowledge of the incident to the Oklahoma State Department of Health and failed to report an allegation of verbal and physical abuse, by a certified nurse aide toward a resident, to the Nurse Aide Registry. The facility daily census report identified 24 residents on the secured unit and 62 total residents. Findings: An undated facility policy, titled Allegations of Abuse, documented in part, .All alleged violations involving abuse .are reported immediately, but not later than 2 hours after allegation is made .Report the results of all investigations to: Oklahoma State Health Department, Department of Human Services, Ombudsman, Resident Representative/Family/POA, Physician, Licensing Boards, Police, Other appropriate agencies . Resident #3 had diagnoses which included dementia with other behavioral disturbances. An incident report with an incident dated of 08/15/24, was sent to OSDH and documented the facility received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to report an allegation of abuse, within two hours of staff knowledge of the incident,`to the Oklahoma State Department of Health and failed to report an allegation of verbal and physical abuse, by a certified nurse aide toward a resident, to the Nurse Aide Registry for one (Resident #3), and failed to take appropriate corrective action to extirpate the risk of abuse for three (#2 and #3) of four residents whose clinical records were reviewed for abuse. The facility roster identified 62 residents. Findings: An undated facility policy, titled Allegations of Abuse, documented in part, .All alleged violations involving abuse .are reported immediately, but not later than 2 hours after allegation is made .Report the results of all investigations to: Oklahoma State Health Department, Department of Human Services, Ombudsman, Resident Representative/Family/POA, Physician, Licensing Boards, Police, Other appropriate agencies .If alleged violation is verified appropriate corrective action must be taken . Resident #1 had diagnoses which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure beneficiary notifications were provided to two (#38 and #54) of three residents reviewed for beneficiary notification. The DON identified seven residents who received skilled services in the facility. Findings: Resident #38 admitted to Part A skilled services on 09/16/23 and discharged from Part A services on 10/15/23. They had 70 days remaining. The SNF Beneficiary Protection Notification Review form documented an SNF ABN CMS-10055 was provided to the resident however no copy was provided to surveyors. The Review also documented therapy had given verbal notice of the NOMNC but no documentation was provided as evidence. Resident #54 admitted to Part A skilled services on 08/24/23 and discharged from Part A services on 09/22/23 They had 71 days remaining the SNF Beneficiary Protection Notification Review documented Res #54 received a SNF ABN form CMS-10055 but a copy was not provided. The review also documented verbal notice was given by therapy for the NOMNC CMS 10123 however, no documentation was provided as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure safe Hoyer lift transfer for one (#14) of one observed during Hoyer transfer. The DON identified eight residents who required Hoyer transfer in the facility. Findings: Resident #14 admitted with diagnoses which included dementia, anxiety, and hypertension. A quarterly assessment dated [DATE], documented Resident #14 required transfer assistance with mechanical lift and two people assist. A care plan, revised 06/12/23, documented Resident #14 was totally dependent for transfer assistance with two people. On 02/20/24 at 1:40 p.m., Resident #14 was observed to be alone in room [ROOM NUMBER], in the Hoyer lift sling, with their bottom touching the bed and their head and shoulders lifted above the bed. On 02/20/24 at 1:44 p.m. CNA #1 walked by room [ROOM NUMBER], stopped, looked back into the room and continued to walk to LPN #1 and asked where the other CNA was. LPN #1 stated they were in the room with Resident #14. CNA #1 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a water management program was created, utilized, and monitored for Legionella. The care coordinator identified 58 residents who resided at the facility. Findings: Review of the infection control policy revealed no policy for water management. On 02/23/24 at 09:45 a.m., the care coordinator stated the maintenance personnel ensure unused shower rooms and bathrooms were closed and capped off, but the facility did not have a policy specific to water management. They stated water was not monitored or tested for pathogens, but no residents had been diagnosed with water pathogen illnesses.

Based on observation, record review, and interview, the facility failed to ensure the required number of staff were present when the mechanical lifts were operated for two (#5 and #9) of two residents reviewed for mechanical lifts. The DON reported 23 residents required the use of mechanical lifts. Findings: A Lifting Machine, Using a Portable policy, undated, read in part .Two nursing assistant will be required to perform the lift machine . 1. Resident #5 had diagnoses which included vascular dementia. A care plan, dated 06/30/22, documented the resident required extensive assistance with transfers. On 11/20/23 at 3:41 p.m., CNA #2 was observed completing the transfer of Resident #5 from the bed to their chair using the mechanical lift. The lift sling was under the resident. No other staff was present in the room. The surveyor asked CNA #2 how many aides or staff were required to transfer a resident with a mechanical lift. CNA #2 stated they transferred residents alone when they could not find assistance. The CNA stated the facility policy required two staff present to use the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to maintain a quality assurance and performance program. The Census and Conditions identified 60 residents currently reside in the facility. Findings: A facility policy, titled Quality Assurance and Performance Improvement, read in part .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcome of care and quality of life .The QAA Committee shall be interdisciplinary and shall .Consist at a minimum of .The Director of Nursing Services .The Medical Director or his/her designee .At least three other members of the facility's staff, at least one of which must be the administrator, owner, a board member or other individual in a leadership role, and .The Infection Preventionist . On 01/03/23 during the entrance conference with the administrator a request was made for the facility QAPI plan. No documentation was provided by the administrator to indicate the facilty had a QAPI plan. On 01/09/23, at 3:10 p.m., the administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to maintain a quality assurance and performance program. The Census and Conditions identified 60 residents currently reside in the facility. Findings: A facility policy, titled Quality Assurance and Performance Improvement, read in part .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcome of care and quality of life .The QAA Committee shall be interdisciplinary and shall .Consist at a minimum of .The Director of Nursing Services .The Medical Director or his/her designee .At least three other members of the facility's staff, at least one of which must be the administrator, owner, a board member or other individual in a leadership role, and .The Infection Preventionist . On 01/09/23, at 3:10 p.m., the administrator was asked for documentation of the QAA program. The administrator stated the facility did not have a QAA committee.

Based on record review and interview the facility failed to monitor/ensure twice weekly testing of facility staff, who were required to test, for COVID-19. This has the potential to affect all residents in the facility. The Census and Conditions documented 60 residents reside in the facility. Findings: an undated policy, titled Coronavirus Disease (COVID-19)- Testing Staff, read in part .Asymptomatic staff who are not up-to-date with all recommended COVID-19 vaccine doses are routinely tested based on the level of community transmission reported in the previous week . On 01/06/23 at 3:05 p.m., the MRP #1 stated they were responsible to track and record all staff COVID-19 testing results. MRP #1 stated the staff tested themselves and either left the test at the nurses station, or send a picture of the test results to them. The MRP #1 stated they had a record of all tests taken, but did not monitor to ensure all staff were tested twice weekly. On 01/06/23 at 3:33 p.m., the administrator was asked if anyone besides MRP #1 kept records of staff COVID-19 testing. The administrator stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to implement and maintain an effective infection control program. The facility failed to track and trend infections and the use of antibiotics for October, November, and December of 2022. This had potential to affect all residents in the facility . The Census and Condition identified 60 residents in the facility Findings: An undated facility policy, titled Policies and Practices- Infection Control, read in part .The objectives of our infection control policies and practices are to: . Prevent, detect, investigate, and control infections in the facility .Maintain records of incidents and corrective actions related to infections . On 01/06/22, at 10:05 a.m., the DON provided the documentation of infections and antibiotic use to the survey team. The DON stated it was incomplete but that was all the documentation available. Examination of the antibiotic stewardship record book revealed no tracking and trending of infections and antibiotic use in the facility for October, November, or December of 2022. On 01/06/22, at 3:30 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.