Cedar Manor Nursing and Rehabilitation Center

Inspectors wroteBased on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a therapeutic recreation specialist or an activity professional for 1 of 1 activity director (AD) reviewed for qualifications. The facility failed to ensure the AD was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.

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 as evidence by: The facility failed to ensure:A. Dietary Manager and [NAME] D wore a hair restraint properly covering all of their hair. B. The bottom shelves throughout the kitchen were clean and not soiled. C. The stove and oven were clean and not soiled. D. The vent hood was clean and free of dust. E. The freezer in the pantry was clean and not soiled. F. The shelves in the pantry were clean and free of dust. These failures could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated.

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 communicable diseases and infections for 2 (Resident #3 and #21) of 5 residents reviewed for infection control. LVN A failed to sanitize the glucometer after she performed a blood sugar test on Resident #21. CNAs B and C failed to use recommended PPE when they assisted Resident #3 with incontinent care and urinary catheter care as the resident was on EBP precautions. These failures could place residents at risk of cross contamination and the spread of infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure each room was designed or equipped to assure full visual privacy for 6 of 6 dual occupancy rooms reviewed for privacy in the facility. The facility failed to ensure that dual occupancy rooms were provided with ceiling suspended curtains, which extended around the bed, to provide total visual privacy. This failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and sanitary environment for residents, staff and the public, as evidenced by; An industrial sized garbage can dumpster was seen outside the facility and not on a concrete slab. These failures could affect residents and could result in unsanitary conditions by creating a haven for pests could cause disease for the residents.

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 to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #1 and #2) of 5 residents reviewed for infection control. The facility failed to ensure RN A and MA B used personal protective equipment during a transfer when the residents were on enhanced barrier precautions. The facility failed to ensure RN A washed his hands correctly while completing wound care on Resident #1. These failures could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 6 resident halls (Hall 3) reviewed for environmental concerns. The facility failed to replace missing and damaged ceiling panels in Hall 3. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure nurse staffing information was posted in a prominent place readily accessible to residents and visitors that included: The total number and the actual hours worked by the registered nurses, licensed practical nurses or licensed vocational nurses and certified nurse aides directly responsible for resident care per shift for 12 of 12 days [KS1] (8/9/25, 8/10/25, 8/11/25, 8/12/25, 8/13/25, 8/14/25, 8/15/25, 8/16/25, 8/17/25, 8/18/25, 8/19/25, 8/20/25)reviewed for required postings. The facility failed to ensure the daily staffing information up to date and was posted in a prominent location on 08/20/25. This failure could place residents, their families, and visitors at risk of not knowing how many nursing staff are currently working to provide care on all shifts. [...]

Inspectors wroteBased on interview, and record review the facility failed to review and revise the Comprehensive Care Plan by the interdisciplinary team after each assessment for 1 (Resident #1) of 13 residents. The facility failed to update the care plan for fall interventions for Resident #1 after a fall assessment was completed on 04/13/2025. This failure could affect residents of the facility by placing them at risk for decreased quality of care.

Inspectors wroteBased on observations, interviews, and record reviews 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 infections for 1 of 4 residents (Resident #1) reviewed for infection control. The DON and RN A failed to follow EBP procedures by not wearing a gown while providing Resident #1 wound care. This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 2 meals reviewed for resident rights and for 10 of 10 residents in the confidential group interview. The facility failed to serve residents in the female secure unit in a manner that was not institutional-like and serve residents on trays. The facility failed to ensure staff provided care to residents while not on their cell phones causing residents to feel left out. This failure could place residents at risk for decreased meal satisfaction and could result in a diminished quality of life for the identified residents and could affect additional residents by causing a loss of self-esteem and increased isolation.

Inspectors wroteBased 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 one of one (Resident #15) residents reviewed for wound care. The facility failed to ensure that RN B changed her gloves and performed hand hygiene while providing wound care to Resident #15. This failure could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have certified resident rooms equipped for adequate nursing care, comfort, and privacy for 33 of 85 rooms (Rooms 701-710, 712-714, 717-722, 801-813, and 815). The facility failed to have 38 Title 18 beds in B Building resident ready. The facility failed to have 24 Dually Certified (Title 19/19) beds in B Building resident ready. This failure could affect residents by placing them at risk of residing in rooms without proper furnishings and privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan was developed and implemented describing services to be furnished to maintain the resident's highest practicable physical well-being, including services that are not provided due to the resident's exercise of the right to refuse care for 1 of 2 residents (Resident #1) reviewed for care plan revisions The facility failed to ensure Resident #1's care plan was revised to indicate the preference to keep socks on during skin assessment. These failures could place residents at risk of receiving inappropriate care.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of medical records. The facility failed to accurately document Resident #1's ulcer assessment for new wounds to her left foot. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure communication with hospice representatives in the provision of care for 1 (Resident #1) of 2 residents reviewed for hospice coordination of care,: The facility did not keep written documentation of communication between hospice and facility per hospice contract. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, in 4 rooms (Rooms #103, #106, #203, #204) and one of 3 shower room for halls 100 and 200 reviewed for accident hazards, in that; The facility failed to ensure that the hot water temperatures in the restroom sinks for 4 resident rooms and the shower rooms did not exceed the maximum of 110 degrees Fahrenheit. This failure could place residents at risk for injuries related to hot water temperatures.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #55) of two residents reviewed for pain in that , 1. RN A failed to accurately assess and administer pain medication to Resident #55 when she complained of left arm pain. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, based on a comprehensive assessment, residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition for one (Resident #55) of two residents reviewed for pain. 1. RN A administered ABH cream which was prescribed for agitation or anxiety when Resident #55 complained of left arm pain. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life.