Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Ridge Health & Rehab Ctr during CMS and state inspections, most recent first.
Undated Multi-Use Aplisol Vial: An LPN was observed retrieving an opened vial of Aplisol from the med refrigerator with no date showing when it was opened or when it would expire. The vial label stated to refrigerate, protect from light, and discard the in-use vial after 30 days. The Wound Nurse, covering for the DON, stated that multi-use vials including TB solution should be dated when opened.
Unsanitary kitchen conditions were observed during meal service when cooks plated food from the steam table beneath a ceiling vent that was pointed down toward the food. The vent, nearby ceiling, light, and adjacent wall had visible greasy dirt and/or lint, and the Dietary Mgr stated there were no cleaning logs while a dietary aide said the area had been wiped down about a week earlier. The Admin and Regional Dir of Dining acknowledged the issue and noted the steam table may have been moved from its prior location.
Multiple residents with significant mobility and cognitive impairments experienced unsafe conditions when staff failed to follow transfer and fall-prevention practices. A resident fell in the shower after being placed on a small shower chair without brakes and without a gait belt. Another resident, care planned for a non-skid mat after sliding from a w/c, was later observed being transferred without the mat in place. A third resident, fully dependent for mobility, was left hanging in a mechanical lift without hands-on support when the lift battery failed and staff attempted to complete the transfer with the lift legs stuck. A fourth resident, care planned for fall mats and a low bed due to dementia and multiple comorbidities, was observed in bed while the fall mat was folded and stored at the head of the bed instead of positioned for use.
A deficiency was cited after multiple residents and a family member reported that meals were often cold, bland, or otherwise unappetizing. Residents in rooms and isolation said food arrived cold by the time it was served, including substitute items, and facility leaders acknowledged delays in tray assembly and transport that contributed to the complaints. Resident Council minutes and a grievance summary also documented ongoing concerns about cold food and late trays.
Two residents did not receive timely and hygienic incontinence care as required by their care plans and facility policy. One resident with multiple comorbidities and total dependence for toileting and hygiene remained in saturated linens and briefs from overnight into late morning on multiple occasions before CNAs provided care. Another resident, always incontinent of bowel and bladder, received peri-care in which CNAs repositioned the resident onto stool-soiled linens, allowed a stump to move through stool, and touched the pubic area with soiled gloves, leaving stool residue before completing cleansing. These practices did not align with the facility’s incontinence care policy for keeping skin clean, dry, and free of contamination.
A resident with multiple health issues experienced ongoing pain during peri-care due to inadequate pain management by facility staff. Despite having a care plan for pain management, staff failed to document pain scores, offer breaks, or apply the prescribed barrier cream, leading to the resident expressing significant discomfort. Facility policies on pain management were not followed, resulting in the resident's ongoing pain and discomfort.
The facility failed to maintain resident dignity during feeding and ensure call lights were accessible for four residents. A CNA was observed standing while feeding two residents, contrary to policy, and two residents had call lights out of reach, affecting their ability to request assistance. These actions violated the facility's policies on meal assistance and call light accessibility.
The facility failed to provide adequate feeding assistance to residents dependent on staff for meals. A resident with moderate cognitive impairment was left without help, while another with severe impairment began eating only after assistance arrived. A cognitively impaired resident was found with an untouched meal tray and no staff present, and another resident struggled to eat due to hand pain and lack of assistance. These instances show a failure to adhere to the facility's policy on maintaining residents' nutrition.
The facility failed to supervise residents adequately, leading to unsafe transfer practices and potential safety hazards. A resident was transferred using a mechanical lift without proper contact, causing her to swing freely. Another resident's call light was out of reach, increasing fall risk. Additionally, a resident was allowed to keep cigarettes and a lighter, violating the facility's smoking policy.
The facility failed to provide adequate incontinent care for several residents, leading to deficiencies. One resident was left in wet pants, while others received incomplete cleaning during care. CNAs did not clean all necessary areas or apply skin protective lubricant, as required by the facility's policy. These actions affected residents with various medical conditions, including cognitive impairments and incontinence.
The facility failed to provide palatable and attractive food to residents, with several expressing dissatisfaction with the taste and appearance of meals. Observations confirmed issues such as tough meat and bland vegetables, contrary to the facility's Food and Nutrition Services Manual standards.
The facility failed to perform proper hand hygiene and glove changes during resident care. A CNA fed two residents without hand hygiene, and an RN administered medications without hand hygiene, handling pills with bare hands. Additionally, two CNAs did not change gloves or perform hand hygiene during incontinent care, using the same towel and gloves throughout the process, contrary to facility policies.
The facility failed to confirm the need for antibiotics and ensure residents received all doses as ordered, affecting five residents. The Infection Preventionist could not confirm specific infections or reasons for antibiotic use, and the infection control log lacked essential details. One resident experienced significant medication errors with multiple missed doses of prescribed antibiotics, which could potentially worsen the infection. These deficiencies indicate a failure to adhere to the facility's Antibiotic Stewardship Policy.
A resident with a history of chronic osteomyelitis, cellulitis, and diabetic foot ulcers did not receive proper wound care as per the prescribed orders. The dressing on the resident's left foot was found to be improperly applied, missing essential components, and saturated with drainage. The facility lacked a policy on diabetic ulcer care, contributing to the deficiency.
A resident readmitted with pressure sores did not receive timely skin assessments or appropriate treatment, despite being at high risk for skin breakdown. Staff failed to consistently implement care plan interventions, leading to inadequate pain management and communication lapses. The facility did not adhere to its policies for pressure ulcer prevention and management.
A resident with a wound infection did not receive multiple doses of prescribed IV antibiotics, Ceftriaxone and Vancomycin, as documented in the MAR. The facility's policy required proper administration and documentation, which was not followed, leading to significant medication errors. The pharmacist confirmed the severity of the missed doses.
Undated Multi-Use Aplisol Vial
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles when a multi-use vial of Aplisol, a TB testing solution, was found in the medication refrigerator with no date documenting when it was opened or when it would expire. On 3/10/2026, an LPN retrieved the opened bottle from the medication storage room and stated she did not know when it had first been opened. The vial label stated to refrigerate, protect from light, and discard the in-use vial after 30 days. The LPN also stated that the entire facility would use this medication. On 3/12/2026, the Wound Nurse, covering for the DON, stated that multi-use vials including TB solution should be dated when opened. The facility policy states medications are to be stored in a safe, secure, and orderly manner and in accordance with state and federal regulations, and the CMS-671 documented 106 residents in the facility.
Unsanitary kitchen vent and steam table placement during meal service
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen during lunch service. During observation, two cooks were serving food from the steam table onto plates and then placing the plates on trays for delivery to residents. Directly above the steam table was a ceiling vent with vents pointed down toward the food, and the vent, the surrounding ceiling, the nearby light, and the adjacent wall were observed to be dirty with greasy dirt and/or lint. The Dietary Manager stated there were no cleaning logs and that a dietary aide was told to clean the walls about once a week. The dietary aide stated the walls and ceiling had been wiped down about a week earlier. When shown the buildup on the vent, ceiling, wall, and light, the Dietary Manager acknowledged the grime and stated the steam table was blowing directly onto the steam table and may have been moved from its prior location. The Administrator stated the dietary department should follow its policies on cleaning and food preparation, and the Regional Director of Dining stated the staff had reported the grime and sent a picture of it, agreed it did not appear to have been cleaned lately, and said the area had been cleaned and the steam table might be moved back.
Failure to Ensure Safe Transfers, Fall Interventions, and Proper Equipment Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfers, implementation of fall interventions, and provision of appropriate equipment, resulting in accidents for multiple residents. One resident with hemiplegia, COPD, atrial fibrillation, and other conditions, cognitively intact and requiring partial/moderate assistance with wheelchair transfers and showers, slipped and fell in the shower. The resident reported that a CNA did not use a gait belt, transferred her onto a small shower chair without brakes, and the chair moved out from under her during the transfer, causing her to fall onto the shower floor and bruise her side. The CNA later stated she used the small shower chair because the other type was not available, confirmed the chair had no brakes, and acknowledged the resident did not have a gait belt on. Another resident with facial weakness after cerebral infarction, diabetes with CKD, dysphagia, and other diagnoses was identified as high risk for falls and required partial/moderate assistance with transfers. After this resident was found on the floor and reported having tried to get to the bathroom and sliding out of the wheelchair, the root cause was identified as slipping from the wheelchair and an intervention of a non-skid mat to the wheelchair was documented. However, during a later observation of a CNA transferring this resident from bed to wheelchair, no non-skid mat was present on the wheelchair seat, and subsequent inspection by an RN confirmed there was no non-skid mat in the wheelchair or anywhere in the room, indicating the fall intervention was not in place as planned. A third resident with metabolic encephalopathy, pulmonary fibrosis, hemiplegia, chronic respiratory failure, CHF, and repeated falls, who was moderately cognitively impaired and dependent on staff for all mobility and transfers, was observed being transferred via mechanical lift by two CNAs when the lift battery failed, leaving the resident suspended in the air with the lift legs stuck in the closed position. One CNA stated they would have to transfer the resident sideways, then removed her hands from the resident and sling, leaving the resident hanging from the lift without staff support while the other CNA operated the emergency release and the wheelchair was repositioned and tilted to complete the transfer. A fourth resident with dementia, COPD, PVD, prior MI, artificial hip, osteoarthritis, knee pain, and total dependence for ADLs, who was incontinent and care planned for fall risk with interventions including fall mats and keeping the bed in low position, was repeatedly observed in bed with the fall mat folded and stored upright at the head of the bed rather than in use. The administrator stated there was no fall prevention policy, only a statement at the end of another policy, while existing policies required safe transfers using gait belts and lifts and required IDT investigations and implementation of appropriate interventions after accidents.
Cold, Unappetizing Food Served to Multiple Residents
Penalty
Summary
Food and drink were not consistently palatable, attractive, or served at a safe and appetizing temperature for 6 of 10 residents reviewed. Multiple residents stated the food was cold, bland, or otherwise not good. R45, who was cognitively intact, said the food was not good and was sometimes warm and sometimes cold. R58, who had moderate cognitive impairment and was eating in his room under contact and droplet isolation, said the food was terrible, tasted like institutional food with no taste, and was always cold by the time he received it. R60, who was cognitively intact and in isolation for COVID, said the food was lousy, bland, and most of the time cold. R17, who had moderate cognitive impairment and ate in her room, said the food was not good and cold by the time she got it, and she usually had it warmed up. R20, who was cognitively intact, said the food was always cold, including substitute items such as a cheeseburger, and that the meat in salads was lunch meat. A family member of R9 also stated the food was always cold when eating meals with the resident. The administrator, dietary manager, and regional director of dietary all acknowledged complaints about cold food and described delays in tray assembly and transport. The administrator stated the facility had been working on the cold food issue and noted trays had been left on the counter before being placed in the warming cart. The dietary manager stated the facility had just started plating food one at a time, placing each plate on an insulated bottom, covering it with an insulated top, adding drinks, and then placing it in the warming cart. The regional director of dietary stated cooks had been plating several plates at the steam table, then transferring them to the counter for drinks and dessert before the trays were put on a cart, which created a delay. Resident Council minutes from September 2025 through February 2026 repeatedly documented concerns about cold food, cold eggs, and trays arriving late, and a grievance summary also recorded a resident complaint that food from the kitchen was cold.
Failure to Provide Timely and Hygienic Incontinence Care
Penalty
Summary
The deficiency involves failure to provide timely and complete incontinence care and proper peri-care technique for two residents. One resident with dementia, CKD stage 3, polyneuropathy, osteoarthritis, depression, a history of pressure ulcers, and documented bowel and bladder incontinence was care planned as dependent on staff for toileting, bathing, and personal hygiene, with interventions including peri-care after each incontinent episode and use of barrier products. Surveyors observed this resident’s bed linens saturated with urine and noted a strong urine odor when the resident was transferred from bed to a recliner. On the following day, the resident reported during breakfast that she had not been cleaned up, remained wet from overnight, and later that morning still had not been checked or cleaned. When CNAs eventually provided peri-care, the incontinence brief was observed to be saturated with urine. CNAs interviewed stated they check residents every two hours and perform incontinence care when getting residents up in the morning, indicating a delay between overnight incontinence and morning care for this resident. The second resident, cognitively intact and always incontinent of bowel and bladder per the MDS and care plan, was to be checked and changed every two hours and PRN. During observed incontinence care, the resident was incontinent of urine and stool. CNAs cleansed only part of the buttocks and anal area, then repositioned the resident onto her back on a stool-soiled bath blanket. While cleansing the peri-area and inner thighs, the resident’s stump moved through stool, and the CNA touched the pubic area with soiled gloves, leaving stool on the pubis. The resident was then turned again and the anus and inner thighs were cleansed. These actions did not follow the facility’s Incontinent Care policy, which requires washing all soiled skin areas, drying well, and changing gloves and performing hand hygiene as required to prevent cross-contamination.
Inadequate Pain Management During Peri-Care
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as R10, who was experiencing ongoing pain during peri-care. R10 was readmitted to the facility with multiple diagnoses, including surgical aftercare on the digestive system and acute and chronic respiratory failure. The resident was moderately cognitively impaired and dependent on staff for various activities of daily living. Despite having a care plan that included interventions for pain management, the facility did not adequately address R10's pain during peri-care, as evidenced by the resident's verbal and non-verbal expressions of pain. On multiple occasions, staff members, including CNAs and an LPN, were observed performing peri-care on R10 without adequately managing the resident's pain. During these care sessions, R10 expressed significant discomfort, crying out in pain and grimacing when reddened areas with open wounds were wiped. The staff failed to document pain scores on the day of the observation and did not offer R10 any breaks or alternative pain-relieving measures during the care process. The CNAs applied petroleum-based ointment instead of the prescribed barrier cream, which was not in R10's active orders at the time. The facility's policies on Activities of Daily Living Support and Management of Pain emphasize the importance of appropriate pain management and resident comfort. However, the staff did not adhere to these policies, as they did not promptly assess or address R10's pain, nor did they document or report the resident's pain complaints effectively. The facility administrator stated that CNAs are expected to report pain to other staff, but this expectation was not met in R10's case, leading to inadequate pain management and ongoing discomfort for the resident.
Failure to Ensure Resident Dignity and Accessibility of Call Lights
Penalty
Summary
The facility failed to uphold resident dignity during feeding assistance and ensure call lights were within reach for four residents. A Restorative CNA was observed standing while feeding two residents simultaneously, which is against the facility's policy that requires staff to sit while assisting residents with meals. One resident, who was cognitively intact but dependent on staff for eating, was fed in this manner, while another resident, who was severely cognitively impaired, required moderate assistance but was documented as needing to eat independently. The Director of Nursing later intervened by providing a chair to the CNA, indicating a lapse in adherence to the facility's meal assistance policy. Additionally, the facility did not ensure that call lights were within easy reach for two residents, compromising their ability to call for assistance. One resident, who was cognitively intact and dependent on staff for most activities of daily living, had a call light on the floor and another hooked to a privacy curtain, making it inaccessible. Another resident, who was severely cognitively impaired and required substantial assistance, had a call light placed on a fall mat on the floor, out of reach. Despite the facility's policy requiring call lights to be within reach, these instances demonstrate a failure to comply with established procedures, impacting the residents' ability to exercise their rights to self-determination and communication.
Failure to Provide Adequate Feeding Assistance to Residents
Penalty
Summary
The facility failed to provide adequate feeding assistance to residents who were dependent on staff for their meals. Resident R24, who has a moderate cognitive impairment and requires supervision and cueing for eating, was observed sitting at a dining table without touching his food. The CNA present was the only staff member assisting multiple residents and was unable to provide the necessary assistance to R24. Similarly, Resident R59, with severe cognitive impairment requiring substantial assistance, was left without help until another CNA arrived, at which point R59 began eating. Both residents had care plans indicating their need for assistance, yet the facility did not ensure staff availability to meet these needs. Resident R11, who is cognitively impaired and requires supervision for eating, was found in bed with an untouched breakfast tray and no staff present to assist. Despite expressing a desire to eat, R11 did not receive the necessary help, and the tray was removed without any food being consumed. Resident R37, with mild cognitive impairment and requiring setup assistance, was observed eating with his hands due to difficulty using silverware and opening food containers. R37 reported pain in his hands and a lack of staff assistance, which hindered his ability to eat. The facility's policy mandates providing necessary services to maintain residents' nutrition, yet these instances demonstrate a failure to adhere to this policy, resulting in unmet nutritional needs for the residents involved.
Inadequate Supervision and Unsafe Practices in Resident Care
Penalty
Summary
The facility failed to provide adequate supervision and safe transfer practices for several residents, leading to potential safety hazards. One resident, who requires a mechanical lift for transfers due to multiple health conditions including Parkinson's and amputations, was observed being transferred in a manner that caused her to swing freely in the lift. This was due to improper handling by the CNAs, who did not maintain contact with the resident during the transfer, causing her to feel unsafe and at risk of falling. Another resident, who is mildly cognitively impaired and requires substantial assistance, was also transferred using a mechanical lift without proper contact, allowing her to swing freely. This lack of supervision during the transfer process indicates a failure to adhere to the facility's policy on safe lifting practices, which requires staff to ensure the stability and security of the lift and sling before moving residents. Additionally, the facility did not implement adequate fall prevention measures for a resident at high risk for falls, as evidenced by the call light being out of reach. Furthermore, a resident with a history of smoking in his room was allowed to keep cigarettes and a lighter, contrary to the facility's smoking policy, which mandates staff control over smoking materials. This lack of supervision and adherence to policies poses significant safety risks to the residents.
Inadequate Incontinent Care for Residents
Penalty
Summary
The facility failed to provide timely and complete incontinent care for several residents, leading to deficiencies in care. One resident, who was frequently incontinent of both bowel and bladder, was observed with saturated pants after being assisted out of the restroom. The CNA did not change the resident's wet pants before breakfast, despite having a clean pair available. This resident had a history of urinary incontinence and required assistance with activities of daily living due to multiple medical conditions, including traumatic brain injury and diabetes. Another resident, who was always incontinent of urine and occasionally of bowel, was observed receiving incomplete peri-care. The CNAs did not clean all necessary areas, such as the buttocks and abdominal fold, and failed to dry the resident properly. The resident's care plan required two-person assistance for toileting and transfers, and the resident had severe cognitive impairment, making them dependent on staff for care. Additional observations included a resident who was frequently incontinent of bowel and received inadequate cleaning during incontinent care. The CNAs did not clean all soiled areas or apply skin protective lubricant as required by the facility's policy. Another resident, who was always incontinent of urine and frequently of bowel, was also observed receiving incomplete care, with the CNA using the same towel for multiple areas and failing to clean all necessary parts. These deficiencies highlight a pattern of inadequate incontinent care across multiple residents.
Deficiency in Food Quality and Presentation
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature for seven residents. Interviews with residents revealed dissatisfaction with the taste and appearance of the food, with some residents opting to purchase and store their own food due to the poor quality of meals provided. Observations and record reviews confirmed these complaints, with specific instances of food being described as 'nasty,' 'grubby,' and 'not appealing.' The Resident Council Meeting Minutes also documented ongoing issues with the quality of the food, noting that meat was tough and dinners were not fresh. During a survey, a sample tray was tested, revealing that the stuffed pepper was not intact, with the meat separated from the pepper and the sauce spread over both, while the buttered corn was bland. Additionally, a resident was observed struggling with a tough and hard-to-chew sausage during breakfast, further highlighting the facility's failure to meet its own standards as outlined in their Food and Nutrition Services Manual. The manual specifies that food should be prepared to conserve nutritive value, flavor, and appearance, and be served in a manner that meets residents' needs, which was not adhered to in these instances.
Inadequate Hand Hygiene and Glove Use in Resident Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene and glove-changing protocols, as observed in multiple instances involving both nursing staff and residents. A Restorative CNA was seen feeding two residents without performing hand hygiene between assisting them. One resident was cognitively intact and dependent on staff for eating, while the other had a severe cognitive impairment and required moderate assistance. Additionally, a Registered Nurse was observed administering medications to residents without performing hand hygiene between residents. The nurse handled pills directly with bare hands, which is against the facility's medication administration policy. In another instance, two CNAs were observed performing incontinent care on a resident without following proper glove-changing and hand hygiene procedures. The resident was incontinent of bowel and bladder and required staff assistance for toileting. The CNAs used the same towel and gloves throughout the process, including washing the resident's neck, breast, and vaginal area, and then dressing the resident without changing gloves. This was contrary to the facility's incontinent care policy, which requires changing gloves and performing hand hygiene to prevent cross-contamination.
Deficiencies in Antibiotic Stewardship and Administration
Penalty
Summary
The facility failed to confirm the need for antibiotics and ensure residents received all doses as ordered, affecting five residents. The Infection Preventionist was unable to confirm the specific infections or reasons for antibiotic use for several residents, and the facility's infection control log lacked essential details such as culture results, medical record numbers, and documentation of antibiotic administration. For instance, Resident R39 had an unknown infection with no culture results documented, yet received Linezolid as per the Physician Order Sheet. Resident R85 was similarly affected, with no documentation of culture results or organism identification, yet received Cefdinir for an unspecified infection. Resident R95's records indicated a urinary tract infection, but again, no culture results were documented, and the infection control log did not record the antibiotics administered. These lapses in documentation and tracking highlight a systemic issue in the facility's antibiotic stewardship program. Resident R89 experienced significant medication errors, with multiple missed doses of prescribed antibiotics, including Ceftriaxone and Vancomycin, as documented in the Medication Administration Record. The Director of Nursing acknowledged the issue, and the Pharmacist confirmed the severity of the missed doses, which could potentially worsen the resident's infection. The facility's Antibiotic Stewardship Policy emphasizes appropriate antibiotic use, yet the observed deficiencies indicate a failure to adhere to this policy, compromising resident care.
Failure to Follow Wound Care Orders for Resident with Diabetic Ulcers
Penalty
Summary
The facility failed to follow wound care orders for a resident with a complex medical history, including chronic multifocal osteomyelitis, cellulitis, type two diabetes mellitus with foot ulcer and neuropathy, peripheral vascular disease, and an acquired absence of the right leg above the knee. The resident required substantial assistance for lower body dressing and was dependent on staff for footwear. The care plan outlined specific interventions for diabetic ulcers on the resident's left heel and midfoot, including detailed instructions for wound observation, documentation, and treatment application. On a specific date, the resident's left foot dressing was observed to be not intact, with the gauze saturated and dangling on the floor. The wound care nurse confirmed that the dressing was improperly applied, missing essential components such as an elastic wrap. Despite the wound care orders specifying a detailed dressing procedure, including the use of silver sulfadiazine, collagen hydrogel, and other materials, the staff failed to adhere to these instructions. The facility also lacked a policy on treatment and care for diabetic ulcers, contributing to the deficiency.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate treatment and services to prevent and heal pressure ulcers for a resident, identified as R10, who was readmitted from the hospital with multiple medical conditions, including surgical aftercare, pancreatitis, and respiratory failure. Upon readmission, R10 was noted to have pressure sores on her right and left buttocks. Despite being at high risk for skin breakdown, as indicated by her Braden Scale score, the facility did not complete a skin and wound assessment, measurements, or an initial treatment plan for the pressure ulcers in a timely manner. The facility's policies required daily skin assessments for high-risk residents and immediate initiation of treatment plans upon identification of pressure ulcers, which were not adhered to in R10's case. R10's care plan documented her dependency on staff for activities of daily living and her risk for impaired skin integrity, yet staff failed to consistently implement interventions to prevent further skin damage. R10 reported that staff did not change her frequently enough, and she experienced significant pain during peri-care, which was not adequately addressed. The staff's inaction and lack of communication regarding R10's skin condition and pain management contributed to the deficiency. R10's complaints of pain and the presence of open wounds were not promptly reported to the nursing staff, and appropriate barrier creams were not applied consistently as per the orders. Interviews with staff revealed a lack of awareness and communication regarding R10's skin condition and pain. The wound nurse was not informed of R10's pressure sores until weeks after her readmission, and the necessary skin inspections and assessments were not conducted as required by the facility's policies. The facility's failure to adhere to its own policies and procedures for pressure ulcer prevention and management resulted in inadequate care for R10, highlighting significant gaps in communication and care coordination among the staff.
Significant Medication Errors in Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of intravenous antibiotics. The resident, who was cognitively intact and dependent on staff for certain transfers, had a care plan indicating a risk for complications related to a wound infection, requiring antibiotics. Physician's orders were in place for the administration of Ceftriaxone and Vancomycin to treat the infection. However, the Medication Administration Record (MAR) showed multiple instances where these antibiotics were not documented as administered on specific dates in December 2024 and January 2025. The Director of Nursing acknowledged the missed doses and provided documentation for review, which confirmed the absence of records for morning doses of the antibiotics. The facility's Medication Administration Policy required that medications be administered safely and documented as required, which was not adhered to in this case. The pharmacist confirmed that the number of missed doses constituted a significant medication error, potentially affecting the resident's recovery from the infection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lebanon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evercare Of Lebanon | 0.6 mi | ★★★★★ | 6 | 2 |
| Nexus At Mascoutah | 7.5 mi | ★★★★★ | 3 | 0 |
| Clinton Manor Living Center | 7.9 mi | ★★★★★ | 0 | 0 |
| La Bella Of Mascoutah | 8.1 mi | ★★★★★ | 15 | 0 |
| Evervella Of Swansea | 10.2 mi | ★★★★★ | 20 | 0 |
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