Cedar Manor Nursing & Rehabilitation Center

Inspectors wroteBased on record review, and interviews during an abbreviated survey (2622924), the facility did not ensure a comprehensive care plan was developed and implemented to maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) residents reviewed for behaviors. Specifically, there was no documented evidence of a behavior care plan for Resident # 1 who had a diagnosis of dementia with other behavioral disturbances and had multiple nursing progress notes as well as staff interviews that revealed that Resident # 1 refused care and had behaviors. A review of the facility's Resident Assessment and Care Planning Policy last revised 01/25/2025 documented it is the policy of the facility to maintain accurate and current comprehensive assessment and person-centered plan of care for each resident. [...]

Inspectors wroteBased on record review, and interviews during an abbreviated survey (2622924), the facility did not ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (one) out of 3 (three) residents reviewed for activities of daily living. Specifically, Resident #1 had 2 (two) grievances on file for 08/25/2025 and 09/15/2025 related to care. 1) 08/25/2025 Resident #1's Representative found them in the facility smelling of urine and prior to their arrival a family member was there and reported that staff did not change Resident # 1. 2) On 09/15/2025 Resident #1's Representative found them in the day room requesting to go to the bathroom and Certified Nurse Aide #4 refused to put them on the bedpan and stated the resident is a Hoyer and threw the bedpan. [...]

Inspectors wroteBased on observation, interview, and record review conducted during recertification and abbreviated survey (NY00353725) conducted from 4/6/2025-4/11/2025, the facility did not ensure the residents rights to a safe, clean, comfortable, and homelike environment. Specifically, 1) the facility did not provide adequate amount of bath linens for all the residents; and 2) rooms [ROOM NUMBERS] were observed with displaced base board moldings.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification and abbreviated surveys (NY00364873) from 4/06/2025 to 4/11/2025, the facility did not ensure that each resident who was unable to perform activities of daily living received the necessary care and services to maintain grooming and personal hygiene for three of five dependent residents (Residents #387, # 124, and # 56) reviewed for Activities of Daily Living. Specifically, 1) there was inconsistent documentation that Resident #387 who required assistance with bowel and urinary incontinence had there brief changed every 3 to 4 hours, 2.) Resident #124 was observed with long, dirty fingernails and 3) Resident # 56 stated they had not received a shower or had their hair washed since they were admitted to the facility.

Inspectors wroteBased on resident, family and staff interviews, and record review conducted during a recertification survey, the facility did not ensure that sufficient staff was available to meet the needs of all residents. Specifically, actual staffing levels were repeatedly below facility assessed minimum levels on the following dates (3/8/25, 3/9/25, 3/10/25, 3/22/25, 3/23/25, 4/3/25, 4/5/25 and 4/9/25).

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey from 4/6/25 to 4/11/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration or declination and education provided for 10 of 10 staff (Certified Nurse Aides #8 and #25, Laundry Aide #20, Housekeeping Aide #21, Licensed Practical Nurses #3, #23, #24, Registered Nurses #22 and #27 and Food Service Worker #26), reviewed for COVID-19 vaccinations.

Inspectors wroteBased on observation and interview during the recertification survey from 4/6/2025 to 4/11/2025, the facility did not ensure each resident was treated with respect and dignity. This was evident for 2 residents (Resident #79 and Resident #18) during dining observations. Specifically, 1) Certified Nurse Aides #13 and #18, Occupational Therapist #15 and Home Health Aide were observed standing over Resident #79 while assisting the resident with meals. 2) Resident #18 was fed by staff standing during the meal.

Inspectors wroteBased on interviews and record reviews conducted during a recertification survey it was determined that for 1 of 14 residents (Resident #102) during a resident council meeting, the facility did not ensure each resident was free from misappropriation of resident property. Specifically, the facility did not safeguard packages when delivered to the facility for Resident #102 who reported a missing package 11/15/24 and was not reimbursed until 4/8/25.

Inspectors wroteBased on observation, record review and interview conducted during a recertification 4/6/25-4/11/25, the facility did not ensure that necessary assistance and care were provided to carry out activities of daily living for 1 of 10 Residents (Resident #81) reviewed for activities of daily living. Specifically, Resident #81 was not showered twice a week as per unit showering schedule.

Inspectors wroteBased on observation, record review and interview during the recertification survey from 4/6/2025 to 4/11/2025, the facility did not ensure that needed services, care and equipment were provided to assure that residents with limited range of motion and mobility maintained or improved function based on the residents' clinical condition for one (1) of two (2) residents (Resident #18) reviewed for Position and Mobility. Specifically, Resident #18 with contracture of the right hand was observed on 3 occasions without the use of a right hand gauze roll as per physician order.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 4/6/25-4/11/25, the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident (Resident #92) reviewed for Respiratory Care. Specifically, 1) Resident #92 was observed multiple times receiving oxygen at 5 liters and 3 liters via nasal cannula with a physician order for 2 liters. Resident #92 was also observed with an empty portable oxygen tank while resident sleeping with nasal cannula in place.

Inspectors wroteBased on observation, record review, and interview during the recertification survey from 4/6/2025 to 4/11/2025, the facility did not ensure residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) received services consistent with professional standards of practice for 1 of 1 resident (Resident #439) reviewed for Dialysis. Specifically, there was no documented evidence of consistent assessment and oversight before, during and after dialysis treatment for Resident #439 who received hemodialysis treatments at a community-based dialysis center.

Inspectors wroteBased on record review and interview during a recertification survey from 4/6/25 to 4/11/25, the facility did not ensure each resident's drug regimen was free from unnecessary medication, use for one (1) of five (5) residents (Resident #49) reviewed for unnecessary medications. Specifically, for Resident #49 Hydromorphone 2 mg every 4 hours as needed for pain of four - six was administered two times from March 1 2025-April 6 2025 for pain below four and Hydromorphone 4 mg every four hours for pain of seven -ten was administered four times from March 1 2025 - April 6 2025 for pain below seven. On 3/8/25 at 1:25 PM, 4/1/25 at 09:23 PM and 4/6/25 at 5:43 PM Hydromorphone 2 mg and 4 mg were administered together without a physician order.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/6/25 to 4/11/25, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 2 medication carts (East and South units) and the East unit medication room. Specifically, 1) the East Unit medication cart was left unlocked and unattended in the hallway while the nurse was in the medication room [ROOM NUMBER]) on the South Unit, a blister pack of Metformin 500 mg (13 pills) was left unattended on a medication cart while the nurse went into a resident room to administer medications and 3) the East Unit medication room had an expired medication and biologicals.

Inspectors wroteBased on observation and interview conducted during a recertification survey, the facility did not ensure that waste was disposed in a dumpster that was free of leaks and the dumpster area was maintained in a clean condition. Specifically, garbage debris was observed around the bottom perimeter of dumpster.

Inspectors wroteBased on record review and interview during the recertification survey 4/6/25 to 4/11/25, the facility did not ensure that an ongoing review of antibiotic use protocols and a system to monitor antibiotic use was completed for 2 of 2 residents reviewed for antibiotic stewardship. Specifically, for Residents #78 and #190, the facility was unable to provide an infection/antibiotic tracking report as requested on 4/10/25 that ensured their antibiotic program was implemented to monitor antibiotic use protocols when an antibiotic was prescribed to a resident.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00343399, NY00332174, NY00337805), the facility did not ensure that all alleged violations of abuse, neglect, exploitation or mistreatment including injuries of unknown source was reported in accordance with the Federal Law immediately, but no later than 24 hours after forming the suspicion, if the events that cause the suspicion do not result in serious bodily injury. Incidents were not reported by facility staff to the administration in a timely manner and the facility did not submit the results of all investigations to the New York State Department of Health within 5 working days in accordance with State Law for 3 out of 3 residents (Resident #1, #2, #3) reviewed for abuse. [...]

Inspectors wroteBased on record reviews and interviews during an abbreviated survey (NY00343399, NY00332174, NY00337805), the facility did not ensure the residents right to be free from abuse for 1 (Resident #3) out of 3 residents reviewed for abuse. Specifically, on 4/1/2024 Certified Nurse Assistant #7 witnessed Resident #3 been bopped on the head by Certified Nurse Assistant #5 while in their wheelchair. The incident was not reported to the nursing supervisor or the administrator by the staff until Resident #3 reported the incident to the Medical Director of the Managed Long Term Care during a visit on 4/2/2024, that they were left in the shower for a longtime wearing their adult brief and that Certified Nurse Assistant #5 bopped them on their head using their knuckles because they would not follow their commands.

Inspectors wroteBased on observation, interviews and record review during a recertification survey 1/17/24-1/25/24, the facility did not ensure residents had the right to a dignified existence for 1 resident (#73) observed during dining observation. Specifically, staff were observed standing over Resident #73 while feeding the resident their meal. Additionally, Resident #73 was assisted with their lunch meal while other residents at the same table were not provided their lunch meal in a timely manner

Inspectors wroteBased on interviews and record reviews conducted during recertification survey and abbreviated survey (NY 00322838) conducted from 1/17/24-1/25/24 it was determined that for one (Resident #181) of nine residents reviewed for notification of change, the facility did not notify the resident's representative timely with a change in condition after a fall. Specifically, Resident #181 fell in their bathroom and had pain, but their representative was not notified until two hours later when the representative went to the facility to take the resident to an appointment.

Inspectors wroteBased on record review and interview during the recertification survey conducted from 1/17/24 to 1/25/24 the facility did not ensure that a baseline care plan to address resident needs was developed and/or completed within 48 hours of resident admission for 1 of 3 residents reviewed for hospitalization (Resident #129). Specifically, the Baseline Care Plan for Resident #129 did not address the use of a foley catheter.

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey on 1/17/2024-1/25/2024, the facility did not ensure that needed services, care and equipment were provided to assure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for two of six residents (Residents #11 and #32) reviewed for range of motion. Specifically, Resident #11 was not provided with left resting hand splint device, and Resident # 32 was not provided with bilateral booties or a right handroll as ordered by the physician to prevent further contractures.

Inspectors wroteBased on interview and record review conducted during the Recertification and Abbreviated Survey (NY00300194) from 1/17/24 to 1/25/24, the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible for 1 of 9 residents (Residents #184) reviewed for accidents. Specifically, Resident #184, who required supervision for ambulation with a rolling walker, exited the facility through the front door on 8/27/22 at approximately 10:00 PM independently and undetected by staff, fell and sustained an excoriation to the right elbow with bleeding.

Inspectors wroteBased on, interview and record review conducted during the recertification survey from 1/17/24 to 1/25/24, the facility did not ensure that irregularities identified by the pharmacist and forwarded to the facility were acted upon for 1 of 5 residents (Resident # 82) reviewed for unnecessary medications. Specifically, Resident #82's aspirin was not discontinued as per consultant pharmacist and nurse practitioner agreement. The finding is: The facility's Policy and Procedure for Drug Regimen Review dated 10/23 documented: The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist Finding and recommendations are reported to the director of nursing, the attending physician, and medical director. Resident # 82 diagnosis included, delusional disorder, schizoaffective disorder, and metabolic encephalopathy. [...]

Inspectors wroteBased on observations, record review and interviews during a recertification survey 1/17/24-1/25/24, the facility did not 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 infections. Specifically, the facility did not effectively implement accurate tracking and monitoring of infections and outbreaks among residents and staff on the East Unit, staff did not use Personal Protective Equipment (PPE) correctly in an isolation room.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated survey (NY00329325) conducted 1/17/2024-1/26/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 2 of 9 residents (Resident #183 & #12) reviewed for accidents. Specifically, 1. Resident # 183 did not have an orthopedic follow up as per the hospital discharge summary within the recommended 2-3 week time period and 2. treatment for Resident # 12 was delayed due to the doctor not being updated with observations of possible fracture during reassessment.

Inspectors wroteBased on interview and record review conducted during the recertification and abbreviated survey (NY 0032772) from 1/17/24 to 1/25/24, it was determined that the facility did not operate and provide services in compliance with all applicable state and local laws, regulations, and codes including notification of termination of a service vital to the health and safety of the community. Specifically, the facility is not accepting sharps for disposal from the community despite the COVID-19 Public Health Emergency having ended on May 11, 2023.

Inspectors wroteBased on observations, record reviews and interviews conducted during a Recertification Survey, it could not be ensured that the facility did not ensure that care was provided in a manner to maintain dignity for 1 of 2 residents (Resident #56) reviewed for dignity. Specifically, Resident #56's urinary (Foley) catheter tubing and drainage collection bag were not concealed to maintain dignity and privacy.

Inspectors wroteBased on interviews and record reviews conducted during the Recertification survey, it could not be ensured that the facility, as a fiduciary (trustee) of the resident's funds, safeguarded, managed, and accounted for residents' personal funds deposited with the facility for 1 of 1 (Residents #58) resident reviewed for personal funds. Specifically, the facility did not honor the resident's request to access personal funds.

Inspectors wroteBased on observations, record reviews and interviews conducted during a Recertification Survey, it could not be ensured that the facility reviewed and revised the Care Plan (CP) for nutrition to address an unplanned weight loss for 1 of 5 residents (Resident #30) reviewed for nutrition. Specifically, no new interventions were initiated to address the resident's continued unplanned weight loss.

Inspectors wroteBased on observations, record reviews and interviews conducted during a recertification survey, it could not be ensured that the facility provided timely medical supervision for 1 of 5 residents (Resident #30) reviewed for nutrition. Specifically, the Physician and/or the Nurse Practitioner (NP) were unaware of and therefore did not address the resident's unplanned significant weight loss.