Cedar Hollow Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 (Resident #1) of 6 residents reviewed for infection control. The facility failed on 06/12/26 to ensure infection control procedures were followed when the Staffing Coordinator, CNA B and CNA C provided perineal care, emptied catheter bag, changed linens and transferred Resident #1, who was on enhanced barrier precautions, from the bed to the wheelchair without donning appropriate PPE. This failure could place residents at risk of infection.

Inspectors wroteBased on interview and record review the facility failed to ensure they provided notice to residents when changes in coverage were made to items and services covered by Medicare as soon as reasonably possible for one (Resident #4) of three residents reviewed who received Medicare skilled services but were discharged , in that: Resident #4 was not given a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) when she was discharged from skilled services at the facility. This failure could affect residents who were discharged prior to using all their Medicare benefits and could deny them of their right to be fully informed about services covered or their right to appeal.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to use proper food handling procedures and chemical storage for * 1of 1 facility kitchen reviewed for food lunch preparation. The facility failed to use proper serving utensil during food preparation. The facility failed to properly store chemicals away from ready-to-eat food. This failure could place residents at risk of cross contamination, food borne illness, and negative effects of ingesting potentially harmful non-food substances. Findings Included:Observation on 05/06/26 at 11:48 AM of [NAME] A picked up a prepared grill cheese sandwich with her gloved hand and placed it on plate for lunch services. [...]

Inspectors wroteBased on 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, to meet the needs of each resident for 1 of 5 residents (Residents #1) reviewed for pharmacy services. On 01/06/26 during bedtime, CMA A administered medications to Resident #1; thereafter, the resident vomited. The facility failed to ensure Resident #1's Tramadol HCl was administered according to physician's orders, which caused the resident to miss 1 dose on 01/06/26 for pain. The facility failed to ensure Resident #1's Atorvastatin Calcium was administered according to physician's orders, which caused the resident to miss 1 dose on 01/06/26 for hyperlipidemia (high cholesterol). [...]

Inspectors wroteBased on observation, 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 set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of four residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was implemented when CNA B attempted to transfer the resident himself, instead of using a mechanical lift, which resulted in a fall. Resident #1 was hospitalized and required surgery for a fracture of the left femur. The non-compliance was identified as PNC. The noncompliance began on 11/30/2025 and ended 12/01/2025. The facility had corrected the non-compliance before the survey began. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1 was properly transferred from her bed to her wheelchair. CNA B attempted to transfer the resident by himself, instead of using a mechanical lift, which resulted in a fall. Resident #1 was hospitalized and required surgery for a fracture of the left femur. The non-compliance was identified as PNC. The noncompliance began on 11/30/2025 and ended 12/01/2025. The facility had corrected the non-compliance before the survey began. This failure could place the residents at risk of accident, injury or serious harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four (Resident #1) residents reviewed for respiratory care. The facility failed to ensure Resident #1's nebulizer mask (device used to deliver medication in a mist form through the nose and mouth) was properly stored when not in use on 12/30/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of five (Resident #1) residents reviewed for medication storage. The facility failed to ensure over the counter medication was not on Resident #1's bedside table on 12/30/2025. This failure could place the residents at risk of accidental overdose or misuse of medication.

Inspectors wroteBased on interview and record review, the facility failed to act promptly upon the grievances of the resident group concerning issues of resident care and life in the facility and demonstrate their response and rationale for such response for 4 (11/19/2024, 12/10/2024, 01/07/2025, and 02/12/2025) of 4 Resident Council Meetings, in that: 1. Concerns voiced during the monthly Resident Council Meetings were not addressed following meetings held on 11/19/2024, 12/10/2024, 01/07/2025, and 02/12/2025. 2. The Resident Council members were not notified regarding facility action taken to address and resolve concerns voiced in prior Resident Council Meetings during the next monthly meetings held on 12/10/2024, 01/07/2025, and 02/12/2025. These failures placed the residents at risk for a decreased quality of life and a decreased feeling of well-being within their living environment.

Inspectors wroteBased on observation, 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 objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 residents (Resident #21 and #64) reviewed, in that: 1. The facility failed to create and implement a care plan that reflected Resident #21 used chewing tobacco and kept it at bedside. 2. The facility failed to create and implement a care plan that reflected Resident #64's right-hand contracture and OT services. These failures place all residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for three of five residents (Resident #98, Resident #34, and Resident #79) reviewed for catheter and incontinence care. 1. The facility failed to ensure CNA G and CNA H provided Resident #98 timely and appropriate perineal care after an incontinent episode when they failed to check and change the resident from 06:00 a.m. to 10:25 a.m. and failed to change the surface of the peri-wipes with each stroke on 03/04/25. 2. The facility failed to ensure Resident #34, who was being treated for a urinary tract infection, was provided timely incontinence care during the 06:00 p.m. to 06:00 AM shift 03/03/25 to 03/04/25. 3. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 5 of 10 Residents (Resident #56, Resident #49, Resident # 98, Resident #155, and Resident #34) and 2 of 4 medication carts (nurses cart Hall A) reviewed for pharmacy services. 1. The facility failed to ensure the Nurses Cart Hall did not have unsecured medication containers for Resident#56, and Resident#49. 2. The facility failed to ensure Resident #155 and Resident #34's anti-fungal powder and were stored properly. 3. The facility failed to ensure Resident #34, and Resident #98's Systane eye drops (lubricating drops for dry eye) were stored properly. 4. The facility failed to ensure Resident #34 did not have her AM dose of tums left on the bedside table on 03/05/25. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure food items in the facility refrigerator were dated or labeled. 2. The facility failed to ensure that food items in the refrigerator were not expired. 3. The facility failed to ensure that all canned goods in dry storage were not dented and separated from the other canned goods. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination. Findings Included: Observation of refrigerator 1 and 2 and interview with Dietary Manager on 3/4/25 revealed: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 12 Residents (Resident #98, Resident #155, Resident #49, Resident #79, and Resident #2) observed for infection control. 1. The facility failed to ensure CNA H and CNA G used the required PPE for Resident #98, who was on enhanced barrier precautions due to her venous access device, while providing incontinence care, failed to change gloves and perform hand hygiene during incontinence care and after, and failed to properly handle soiled linens. 2. The facility failed to ensure CNA H and CNA G change gloves and perform hand hygiene during incontinence care to Resident #155 on 03/04/25. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the resident representative and consult with the resident's physician, when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for one (Resident #15) of five residents. The facility failed to notify Resident #15's physician and resident representative of a bruise to her left hand and dime-sized wound on her right underarm This failure could place residents at risk of a delay in medical intervention and a decline in health.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living (ADL) to maintain good grooming and personal hygiene for 2 (Resident #2, Resident #204) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #2 had her fingernails cleaned and trimmed. The facility failed to ensure Resident #204 had showers as care planed three times a week, and as needed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 2 residents (Resident #155) reviewed for peripheral intravenous care. The facility failed to ensure Residents #155's PICC line dressing was changed per the physician's order. This failure placed residents at risk of developing an infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, administering of drugs and biologicals, to meet the needs of each resident for 1 of 4 medication carts (nurses cart hall 100) reviewed for pharmacy services. The facility failed to ensure the Nurses Cart Hall B did not have an expired Tramadol 50 mg HCL table card for Resident #8 This failure could place residents at risk of not having the medication available due to possible diminished effectiveness, and not receiving the therapeutic benefits of the medications. Findings Include: Observation and record review on [DATE] at 09:20 AM of nurses' cart Hall B, with LVN D revealed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene to a resident who is unable to carry out activities of daily living for two of three residents (Resident #2 and Resident #3) reviewed for ADL care. 1. The facility failed to provide Resident #2, who required extensive assistance, with timely incontinence care on 12/10/24 from 9:00 a.m. to 01:30 p.m. 2. The facility failed to provide Resident #3, who required extensive assistance, with timely incontinence care on 12/10/24 from 9:35 a.m. to 01:45 p.m. This failure could place residents at risk of skin breakdown, urinary tract infections and loss of dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for two of eight residents (Resident #1 and Resident # 2) reviewed for quality of care 1. The Facility failed to ensure CNA I used a gait belt when transferring Resident #1 from her wheelchair to the toilet on 12/10/24. 2. The Facility failed to ensure Hospice Aide D used a gait belt when standing Resident #2 up in the bathroom to provide incontinence care on 12/10/24. These failures could affect the residents by placing the residents at risk for discomfort, pain, falls, injuries, and skin tears.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident had the right to be free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed to ensure a safe environment free from abuse for Resident #1 when CNA A entered his room and cut and stabbed him multiple times which caused him to sustained stab wounds to his right neck, left chest, and left arm on [DATE]. The noncompliance was identified as PNC. The IJ was from [DATE] to [DATE]. The facility had corrected the noncompliance before the survey began. This failure caused serious injury resulting in hospitalization and placed the resident at risk of death.

Inspectors wroteBased on observations, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure low temperature dish machine met minimum of 120 F temperature for wash and rinse cycles. 2. The facility failed to ensure fryer was covered when not in use. These failures could place residents at risk for food-borne illness and food contamination.

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 and to help prevent the development and transmission of communicable diseases and infections for five (Resident #70, Resident #80, Resident #09, Resident #65, and Resident #56) of nine residents reviewed for infection control. 1. LVN C failed to perform hand hygiene after providing an Insulin injection to Resident #70. 2. LVN D failed to prevent cross contamination of a bottle test strips used to obtain glucose levels when she carried the bottle into Resident #80's room and returned it to the top of the medication cart. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one (Resident #29) of eight residents reviewed for ADLs. The facility failed to ensure Resident #29 had her fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for two (Residents #29 and Resident #59) of two residents reviewed for feeding tubes. 1. The facility failed to ensure Resident #29's G-tube was flushed with 15-30 ml's water after medication administration and failed to flush between each medication with 15 ml's of water per facility policy. 2. The facility failed to have orders for Resident #29 and Resident #59 for the required amount of water flushes before and after medication administration and between each medication given via the G-tube. These failures could place residents at risk of medication incompatibility and tube obstruction.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a Resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 of 4 Residents (#58 and #73) reviewed for respiratory care, in that: 1) Resident #58 did not have physician orders for changing and dating all oxygen tubing and equipment and the humidity bottle was not labeled or dated. 2) Resident #73's oxygen concentrator's humidifier bottle and oxygen tubing were not labeled or dated.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, for one (Resident #70) of one resident reviewed for dialysis. The facility failed to ensure Resident #70's dialysis communication sheets were completed to coordinate care with the dialysis center. This failure placed residents at risk of not receiving proper care and adequate coordination of care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 7 residents (Resident #1) reviewed for resident rights . The facility failed to ensure Resident #1 always had the call light within reach. This failure could place residents at risk of falling, injury, and unnecessary pain from not being able to call for help.

Inspectors wroteBased on interview and record review, the facility failed to provide an environment that was free from accident hazards over which the facility has control and failed to provide supervision and assistive devices to each resident to prevent avoidable accidents for 1 of 3 resident (Resident #1) reviewed for accidents free of hazards. The facility failed to complete a fall risk assessment for Resident #1 following a fall. This failure could place residents at risk of continued risk of falling without interventions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two of three medication carts (medication cart #1 and Treatment Cart #2) reviewed for medication storage . The facility failed to ensure medication cart #1 and Treatment Cart #2 were locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.