Cedar Health and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, it was determined for 5 out of 41 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, 5 residents had multiple falls without continued attempts at interventions to prevent additional falls. Additionally, one resident had repeated accidents while operating his motorized wheelchair and had been assessed as not safe to operate the motorized wheelchair. Resident identifiers: 1, 39, 43, 53, and 62.

Inspectors wroteBased on observation, interview and record review, for 6 of 41 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified. Specifically, after residents sustained falls there were no interventions or the interventions were reused and a resident did not have hospice services care planned. Resident identifiers: 1, 39, 43, 53, 62 and 64.

Inspectors wroteBased on observation, interview and record review, for 5 of 41 residents, the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, residents complained of cold food and too much processed food. Resident Identifiers: 6, 9, 15, 33, and 75. Findings Included:On 6/22/25 at 2:17 PM, an interview was conducted with resident 33 who stated he had received a cold hamburger with beef that tasted like fake meat. Resident 33 stated it tasted like it had been mixed with something. Resident 33 stated he had provided feedback to the kitchen staff, but it did not seem to help. Resident 33 stated he would eat lunch, but would not eat breakfast or dinner. Resident 33 stated if he wanted something to eat he could ask for a quesadilla. [...]

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and the walk-in refrigerator were open to the air.

Inspectors wroteBased on interview and record review, it was determined for 2 of 41 sampled residents, the facility failed to promote and facilitate resident self-determination through support of resident choice, including the right to choose activities and schedules, and to make choices about aspects of his or her life in the facility that are significant to the resident. Specifically, two residents who were assessed as independent smokers were not allowed to smoke at night. Resident identifiers: 6 and 15.

Inspectors wroteBased on interview and record review it was determined, for 1 of 41 sampled residents, that the facility did not consult with the resident's physician when there was a significant change in the resident physical status, or a need to alter treatment. Specifically, the resident reported breaking his tooth after sustaining a fall and the injury was not reported to the physician. Resident identifier: 39.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 41 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events resulted in serious bodily injury to the administrator, State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, a resident reported a broken tooth to the staff and the SSA and APS were not notified of the injury of unknown source. Resident identifier: 39.

Inspectors wroteBased on observation and interview it was determined, for 1 out of 41 sampled residents, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, a resident did not receive her morning dose of Metoprolol due to the medication being out of stock. Resident identifier 37.

Inspectors wroteBased on observation and interview it was determined, for 1 of 4 residents sampled, that the facility did not ensure that medication error rates were not 5 percent or greater. Specifically, observations were made of 4 medication errors out of 32 medication opportunities that resulted in a medication error rate of 12.5%. A resident's Metoprolol administration was missed due to the medication not being available from the pharmacy, and a Farxiga, Oxycodone, and Potassium Citrate Extended Release tablets were administered crushed and the manufacturer recommended to take the medications whole. Resident identifier: 37.

Inspectors wroteBased on observation and interview it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment or to help prevent the development and transmission of communicable diseases and infections. Specifically, during hallway meal pass, CNAs (Certified Nursing Assistant) did not sanitize their hands between delivery of meal trays to residents dining in their rooms. Additionally, desserts were not covered on the trays delivered to resident rooms.

Inspectors wroteBased on record review and interview it was determined for 6 of 20 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). Specifically, entity reports of multiple abuse allegations were not submitted to the SSA in a timely manner. Resident identifiers: 9, 25, 43, 46, 124 and 225.

Inspectors wroteBased on interview and record review it was determined for 6 of 30 sample residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations were thoroughly investigated and were not reported to the State Survey Agency (SSA) within 5 days of the incident. Specifically, the facility did not thoroughly investigate multiple falls that resulted in fractures. Resident Identifiers: 9, 15, 25, 43, 46 and 124.

Inspectors wroteBased on interview and record review it was determined, for 1 of 30 sampled residents, that the facility did not coordinate assessments with the pre-admission screening and resident review (PASARR) program. Including referring all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Specifically, after a resident was diagnosed with a mental illness and there was no referral for a level II. Resident identifier: 58.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 out of 30 sampled residents, that the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, a resident was not provided assistance with ensuring a resident's shoes were cleaned before putting resident into bed. Resident identifier: 43.

Inspectors wroteBased on interview and record review it was determined, for 1 of 30 sampled residents, that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, a dependent resident was not provided nail care. Resident identifier: 51.

Inspectors wroteBased on observation and interview it was determined that the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, a vial of insulin and insulin pens were open and available for use without an expiration date and without resident identifier information.

Inspectors wroteBased on interview and record review it was determined, for 1 of 30 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiological services. Specifically, a resident's x-ray was not located in the medical record. Resident identifier: 43.

Inspectors wroteBased on observation and interview it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there was a brown substance in the dish machine, there were unclean areas in the kitchen and unlabeled food items.

Inspectors wroteBased on interview and record review, it was determined that the facility did not develop and implement a comprehensive person-centered care plan for 3 of 32 sample residents, consistent with the resident right that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Specifically, fall care plans were not updated and/or implemented as required. Resident identifiers: 19, 31, and 41.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility did not maintain, for 1 of 32 sample residents, acceptable parameters hydration status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible. Specifically, one resident did not receive the required amount of water through a feeding tube. Resident identifier: 41.