Cedar Creek Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food and nutrition services. The facility failed to ensure food items were sealed and properly dated in the refrigerator and the pantry. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles and the expiration date for 1 of 2 medication carts (short hall medication cart) reviewed for medication storage. The facility failed to ensure 3 insulin pens and 2 insulin vials were labeled with the expiration date and discarded within 28 days of opening. This failure could result in residents receiving expired insulin and lead to unstable or elevated blood sugar levels.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for 1 (Resident #40) of 5 residents reviewed for resident rights. The facility failed to ensure a valid MPOA with Resident #40's signature acknowledged before a notary public was on file with Nursing Facility A prior to designating Family Member B as the Responsible Party. The facility failed to establish if Resident #40 wished to designate Family Member B as the Responsible Party at the time of her admission on [DATE] and thereafter when she was alert and oriented and able to make her wishes known. These failures could place residents at risk for a diminished quality of life, loss of dignity and loss of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure the development and implementation of an effective discharge planning process that focuses on the resident's discharge goals for 1 of 5 residents (Resident #40) reviewed for discharge planning. The facility failed to ensure Resident #40's discharge planning goals were reviewed and implemented once her health improved and she was able to make her discharge preferences known. This failure could result in loss of residents' autonomy and rights to determine care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure preadmissions screening for individuals with a mental disorder and individuals with intellectual disability for 1 of 6 residents (Resident #6) reviewed for PASARR accuracy. The MDS Coordinator failed to accurately screen Resident #6 for mental illness upon admission to the facility. This failure could place residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on observation, interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 2 of 8 residents (Resident #6 and Resident #40) reviewed for clinical records. The facility failed to ensure Resident #6's medical diagnoses report, MDS Assessment, and Care Plan were accurately and completely documented with diagnosis of schizoaffective disorder and bipolar disorder. The facility failed to ensure the EMR contained a complete and accurate MPOA with Resident #40's signature along with a signed admission Agreement. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for three (Resident #1, 3, 4) of eight residents reviewed for pharmaceutical services. 1. The facility failed to ensure that RN D documented that she administered Hydrocodone-Acetaminophen Oral Tablet to Resident #3 on Resident #3's Narcotic Sheet.2. The facility failed to ensure Resident #1's tramadol HCl Oral Tablet was documented as administered on 12/16/25 and 12/17/25 as was reflected on Resident #1's Narcotic Sheet. 3. The facility failed to ensure 1 dose of Resident #4's Lorazepam Oral Tablet was wasted when the blister pack was punctured instead of taping the blister pack. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to document temperatures that were taken from: 12/12/25 to 12/18/25 for Breakfast, Lunch, and Dinner and 12/10/25 to 12/11/25 for Lunch and Dinner.2. The facility failed to label discard dates on containers of jalapeno peppers, ketchup, and tartar sauce.3. The facility failed to clean the air conditioner vent in the kitchen. 4. The facility failed to store raw protein food items below fully cooked foods in the freezer. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the resident's right to secure and confidential personal and medical records for one (unknown resident) of 31 residents. The facility failed on 12/20/25 to ensure the privacy of unknown residents by not locking the laptop screen on medication cart (1 of 2), so the residents' information could not be seen and/or accessed by someone walking by. This failure puts residents at risk for confidential health information exposure, psychosocial harm and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable for 1 of 8 residents (Resident #2). The facility failed to ensure RN B did not leave Resident #2's medications inside the resident's room for the resident to take unsupervised on 12/20/25. This deficient practice could affect residents who received medications for treatments and could result in less potent or an adverse effects and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #1) of 1 resident reviewed, in that: The facility failed to maintain the temperature of Resident #1's personal refrigerator was at or below 41 degrees F 12/1/25 to 12/4/25 and was documented 12/5/25 to 12/19/25. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for one of one kitchen. The facility failed to provide palatable food on the sampled foods on test tray: Green beans were cold Turkey was lukewarm Tater tots were overcooked, hard and had no soft potato inside This failure could place residents at risk of not being satisfied with their food or encouraged to increase their personal food intake with an outcome of weight loss and a diminished quality of life.

Inspectors wroteBased on interview and observation, the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service times. The facility failed to ensure residents were offered snacks at bedtimes. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. Confidential interviews during the Resident Meeting on 03/05/25 revealed the facility did not offer snacks at bedtime unless the resident specifically asks for a certain snack. 3 of the 7 residents who attended the meeting and who were diabetic stated they did not receive any snacks with their names on them any time during the day to indicate they needed a snack due to diabetes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. 1. The facility dietary staff failed to wash their hands between tasks and before handling food. 2. The cook used his bare hands, which had not been washed prior to meal service, take rolls from the cooking sheet pan and put them on the plates as he served lunch. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 3 of 12 residents (Residents #27, #4 and #24) reviewed for infection control. 1. The facility failed to ensure proper hand hygiene was performed and the blood pressure cuff and pulse oximeter were sanitized between resident use. 2. The facility failed to ensure proper hand hygiene was performed, going from a clean area to a dirty area, and the scissors used to provide wound care were sanitized prior to use. These deficient practices could place residents who received medications and wound care at-risk for infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 2 resident units/halls (The Short Hall and Long Hall) reviewed for dignity. 1. The facility failed to ensure Resident #11 was provided privacy when she was administered insulin. 2. The facility failed to ensure Resident #27 was provided privacy when she was administered insulin. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #4) reviewed for care plans: The facility failed to develop a person-centered care plan with interventions that addressed Resident #4's physician orders for the use of oxygen therapy. This failure could place residents at risk for not having their needs and preferences met.

Inspectors wroteBased on the observation, interview, and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #4) reviewed for accidents. The facility failed to ensure Resident #4's fall mat was utilized per physician's orders. This failure could place residents at risk for accidents and injuries related to risk for falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 1 resident (Resident #4), reviewed for quality of care. Resident #4's oxygen nasal cannula was not covered or protected from the elements when not in use. This failure could place residents who received respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 resident units/halls (The Long Hall), and 1 of 3 medication carts reviewed for storage of drugs and biologicals. 1. The facility failed to ensure Resident #22 did not have a jar of mentholated ointment (a topical analgesic and decongestant) at the bedside. 2. The facility failed to ensure the medication cart on The Long Hall was locked and secured. These deficient practices could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observation , interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 of 1 (Residents #3) residents reviewed for medical records. The facility failed to ensure Resident #3's Letters of Guardianship were maintained current. This deficient practice could place residents at risk of improper care due to inaccurate medical records and lack of authority to provide consent for services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain effective pest control for 1 of 1 kitchen reviewed for pests. The facility failed to have pest control effectively treat the kitchen for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a resident environment that was free of pests and rodents for 1 of 1 facility reviewed for effective pest control in that: The facility failed to provide a resident environment that was free of pests This deficient practice could place residents at risk of remaining in an environment that was not free of pests and rodents.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the event caused serious bodily injury for 1 of 11 residents (Resident #3) whose records were reviewed for abuse and neglect: Confidential Staff Members A, B, and H failed to report to the administrator about an allegation of neglect of Resident #3 by RN J. These deficient practices could affect residents by contributing to further abuse and neglect.

Inspectors wroteBased on interview and record review the facility failed to ensure A resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming, and personal for 3 of 3 (#1, #4, #5) residents reviewed for ADL care, in that: The showers were not completed due to 1 CNA on the 2-10pm shift on Monday (2/10/2025). 1. Resident #1 did take a shower, after continuous asking of staff. 2. Resident # 4 did not take a shower for the month of January 2025 according to the POC task for CNA's. 3. Resident # 5 did not take a shower for the month of January 2025 according to the POC task for CNA's. This failure could affect residents and result in residents not receiving assistance when needed for daily care.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records and a right to secure and confidential personal and medical records for 3 of 9 (room [ROOM NUMBER], #47 and resident #76) reviewed for privacy and confidentiality, in that: 1. LVN J did not knock on rooms #55 and #47 before entering rooms. 2. LVN Z left her computer open in the hallway, with people passing by, with resident #76's personal information. This could affect and result in resident privacy being violated.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure comprehensive person-centered care plans were developed and implemented for each resident to meet medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment as required for 1 of 1 (Resident #1) resident reviewed for care plans in that: Resident #1's care plan did not have interventions for his left hand contracture to maintain or improve mobility on hand. This could affect all resident with contractures and could result in a decrease in mobility.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable for 1 of 1 (Resident #1) residents in that: Resident #1 had a left sided hand contracture with no devices to maintain or improve mobility on hand. This could affect resident with contractures and could result in a decrease in mobility.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Residents #1) reviewed for comprehensive care plans in that: The facility failed to develop a plan of care to address Resident #1's multiple wounds. This failure could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities which involved 1 of 6 residents (Resident #21) observed during medication administration reviewed for medication errors . 1. LVN C failed to administer Resident #21's losartan and fluticasone nasal spray at the prescribed times. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure residents were free of any significant medication errors, for 1 of 7 residents (Residents #6) reviewed for significant medication errors. 1. The facility failed to administer to Resident #6, lisinopril (a medication which lowers blood pressure) according to the physician's orders. Resident #6 was administered lisinopril while Resident #6 had low blood pressure. 2. The facility failed to administer to Resident #6, hydrochlorothiazide (a medication which lowers blood pressure) according to the physician's orders. Resident #6 was administered lisinopril while Resident #6 had low blood pressure. These failures could place residents at risk for not receiving the therapeutic effects of the medications prescribed.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. Cut onions, cut lettuce, and parmesan cheese were in zip lock bags and did not have a used by date, in the refrigerator. 2. The dish machine temperature/chemical log for February 2024 was missing. 3. The DM did not write on the substitute log the meal for Saturday, 2/3/2024. 4. The facility prepared and stored 9 peanut butter and jelly sandwiches in the resident's snack pantry refrigerator without any indicators to identify when the sandwiches were prepared or when the sandwiches were to be thrown out for food safety. This could affect residents and could result in residents not getting fresh foods, dishes that are not sanitized and cause harm.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen. In the kitchen 1 (left side) of the 2 ovens on the range were not fully functional. This could affect all residents that eat meals from the kitchen and could result in residents not getting warm food cooked in the oven.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Residents #27) reviewed for care plans. 1. The facility failed to support Resident #27's needs for post-traumatic stress disorder (PTSD). These failures could have placed residents at risk for not having their needs met.

Inspectors wroteBased on interviews and record review the facility's interdisciplinary team failed to review and revise the care plan after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 (Resident #12) residents reviewed for revised care plans. The facility failed to revise Resident #12's care plan to remove conflicting plans for Resident #12's diet texture needs. This failure could place residents at risk for harm with conflicting care plans.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as was possible for 1 (Resident #14) of 6 smokers. Resident #14 had a personal lighter that was in her purse. This could affect all residents and could result in a fire.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 1 of 1 medication cart, reviewed for security. The facility failed to attend and secure the short-hall medication cart. This failure could place residents at risk for harm by misappropriation of property and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on record reviews and interviews the facility failed to develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, and Establish policies and procedures to investigate any such allegations, for 1 of 30 residents (Resident #1) reviewed for investigating injuries of unknown origin, in that. Resident #1 was discovered on 6/16/2023 by LVN A with an injury of unknown origin and did not report the injury to the Administrator or the DON. This deficiency could have placed resident at risk for harm by abuse, neglect, and or mistreatment.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 1 of 30 residents (Resident #1) reviewed for reporting injuries of unknown origin, in that. Resident #1 was discovered on 6/16/2023 by LVN A with an injury of unknown origin and did not report the injury to the Administrator or the DON. [...]

Inspectors wroteBased on observations, interviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for professional standards for food service safety, in that: The facility failed to keep personal items and keys out of the food preparation areas. This failure could place residents at risk for food borne illness.