Cedarwood Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to store, handle, and prepare food in the facility kitchen in accordance with food standards when:Foods were not properly labeled with the use by or open dates;Proper hand hygiene was not followed by kitchen staff;Cold foods were not maintained at safe temperatures during food service and,Wet stainless steel pans were stacked before allowing to dry. These failures had the potential for residents to receive food outside the safe use by dates and for the spread of food borne illness in the kitchen to 42 residents receiving food from the kitchen service.1. During an observation on 6/14/26, at 8:08 a.m., in the kitchen freezer, frozen dessert puffs were in an open plastic bag with no open date or use by date. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 17 sampled residents (Resident 41 and Resident 42) received treatment and services to prevent or minimize a decline in functional abilities when:1. The facility did not clarify Resident 41's physician order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents to maintain their function and joint mobility) exercise program and did not communicate the physician order to RNA; and2. Resident 42's order for left hand splint did not include how many hours per day to be applied and it was not documented how long it was worn per day. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rates are not 5 percent of greater when the medication error rate was 15.38 % for four medication errors out of 26 opportunities observed during a medication pass for four of seven residents (Resident 73, Resident 13, Resident 17, and Resident 8):1. Resident 73 was not given Omeprazole (medication to treat acid in the stomach) 30 minutes prior to meal, and2. Resident 8 was not given Omeprazole 30 minutes prior to meal, and3. Resident 17 was given Metoprolol (medication to treat high blood pressure) without checking blood pressure prior to administration, and4. Resident 13's Clopidogrel (medication that prevents clots) was not given on time. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control precautions were followed for two of seventeen sampled residents (Resident 30 and Resident 46) when: 1. Enhanced Barrier Precautions (EBP-an infection control intervention to reduce transmission of [NAME]-drug resistant organisms, MDROs) were not followed for Resident 30 when enteral tube feeding formula (nutrition delivered directly into stomach) was administered without proper PPE (personal protective equipment- supplies such as gowns and gloves used to minimize exposure to infectious organisms), and 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote a dignified environment that maintained resident's dignity and privacy for one of 17 sampled residents (Resident 79), when Resident 79's urinary catheter tubing and bag (tubing which allows urine to drain from the bladder into a collection bag) was not placed in a privacy bag and its contents exposed while the resident was ambulated through the hallway. This failure violated Resident 79's rights to privacy and had the potential to compromise the resident's dignity and self worth. A review of the admission record indicated the facility admitted Resident 79 in the summer of 2026 following hospitalization for left knee joint infection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the skin condition section of the Minimum Data Set (MDS, a standardized assessment and care screening tool) for one of 17 sampled residents (Resident 41), when the MDS did not accurately reflect Resident 41's documented chronic neck wound and right lower extremity venous stasis ulcer (an open sore that develops because blood does not flow properly through the vein). This failure resulted in MDS assessment not accurately representing Resident 41's clinical condition and had the potential to affect care planning for the appropriate care needs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents received adequate supervision to prevent fall accidents and residents' environment remained free of accident hazards for two of 17 sampled residents (Resident 53 and Resident 76) when:The facility did not implement resident specific interventions to provide adequate supervision and safety for Resident 53 after the resident experienced fall with head contusion, and The facility failed to ensure Resident 76's (a non-verbal resident, dependent with care and unable to reposition self in bed or use call light) room was free from hazards when her call light string was observed on the back of her neck and pinned to her pillowcase. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care for one of 17 sampled residents (Resident 30) receiving enteral feeding (nutrition delivered directly into the stomach through a feeding tube) when Resident 30's head of bed was not elevated to 45 degrees at all times. This failure resulted in an increased risk of aspiration (when fluid, food, or gastric acid gets into the airways causing airway blockage or infection) for Resident 30. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary respiratory care consistent with professional standards of practice, goals and preferences for one of 17 sampled residents (Resident 77), when Resident 77's oxygen tubing was not labeled. This failure had the potential for Resident 77 to be exposed to respiratory infectious agents from old or dirty tubing. During an observation on 6/14/26, at 9:15 a.m., in Resident 77's room, Resident 77 was receiving oxygen through a nasal cannula (thin plastic tubing that provides oxygen to the nose) with no label or date on the tubing. During an interview on 6/14/26, at 9:20 a.m., with Respiratory Therapist (RT), RT stated she did not see a date or label on Resident 77's tubing, and there should be one, so we know how old the tubing is (period it has been in use). [...]

Inspectors wroteBased on interview and record review the facility failed to provide pain management that met professional standards of practice and residents plan of care for two of 17 sampled residents (Resident 77 and Resident 80) when:1. Nursing staff did not reassess Resident 77 timely after administering a PRN (as needed) pain medication to check for effectiveness, and 2. The facility did not follow physician's order to assess Resident 80's pain using a pain scale. This failure resulted in the facility being unaware of the effectiveness of the PRN pain medication administered to Resident 77 and had the potential for Resident 77's and Resident 80's pain to not be adequately managed. 1. During a review of Resident 77's Diagnosis information dated 6/16/26 indicated, Resident 77 had the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received their prescribed therapeutic diet (a meal plan prescribed by a physician and tailored by a registered dietitian) for one of 17 sampled residents (Resident 39). When Resident 39 was served lunch with a salt packet, while on a no added salt diet during lunch mealtime. This failure had the potential for Resident 39's chronic medical conditions of high blood pressure and chronic kidney disease to worsen, causing negative health outcomes. During an observation on 6/14/26, at 12:30 p.m., in Resident 39's room, Resident 39 was eating her lunch while in bed, with her family member at bedside. A salt packet was noted on Resident 39's meal tray. Resident 39's meal tray ticket read NAS (No Added Salt). [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a system to monitor COVID-19 vaccination status of staff and education to staff related to benefits and potential side effects of the COVID-19 vaccine. This failure resulted in the facility not having accurate monitoring of the staff's COVID-19 vaccination status with the potential for infection to staff and residents. During an interview on 6/16/26 at 9:44 a.m. with Licensed Nurse (LN 5), LN 5 stated she has received information regarding the COVID-19 vaccine and that it was offered yearly. During an interview on 6/16/26 at 11:23 a.m. with the Infection Preventionist (IP), the IP stated he started as the IP at the facility in January 2026. The IP stated that COVID-19 vaccines are offered to the staff. Requested tracking or monitoring log for staff COVID-19 vaccination status and education. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe equipment for one of 17 sampled residents (Resident 40), when Resident 40's bed control power cord was frayed with exposed wires. This failure placed Resident 40 at risk for injury. A review of Resident 40's admission Record indicated Resident 40 was admitted to the facility in August 2025 with multiple diagnoses including metabolic encephalopathy (change in how the brain works due to an underlying condition causing confusion or memory loss), dementia (loss of memory, language, and thinking abilities that are severe enough to interfere with daily life), chronic obstructive pulmonary disease (lung condition that limits airflow into and out of the lungs), and dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a Minimum Data Set (MDS, a standardized assessment tool used in skilled nursing facilities) Significant Change in Status Assessment (SCSA, an MDS assessment done within 14 days after a resident has a significant change in their health status) was completed for one of six sampled residents (Resident 3) when Resident 3 developed a stage 3 pressure ulcer (tissue damage that results in full-thickness loss of skin and the layer of fat under the skin may be visible) and was not assessed. This failure had the potential to delay wound treatment, placing Resident 3 at risk for increased pain, infection, and a decline in functional status for the resident.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that Minimum Data Set (MDS, a standardized assessment tool used in skilled nursing facilities) assessments accurately reflected residents' current clinical status for two of six sampled residents (Resident 1 and Resident 2), when Resident 1's chest incisions were not coded on the MDS admission assessment and Resident 2's ongoing dialysis (a treatment that filters waste and excess fluid from your blood when the kidneys are no longer functioning) treatment was not coded on a quarterly MDS assessment. These failures could have resulted in Resident 1 not receiving necessary wound care and Resident 2 missing or receiving poorly coordinated dialysis treatments.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food properly in accordance with professional standards for food service safety for a census of 49 when: 1) Two metal bowls and 9 plate cover lids stored wet and stacked, 2) Two plastic cups had white film build up inside the cups, 3) Two thermometers missing inside freezers, 4) Open food items were not labeled with use by date, and, 5) Food items were not covered during resident food distribution of meal trays These failures increased the potential for food borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident needs were accommodated for seven out of 19 sampled Residents (Resident 13, Resident 47, Resident 152, Resident 19, Resident 4, Resident 5, and Resident 10), when 1. The call light was not within reach for Resident 13, Resident 47, Resident 152 and Resident 19; 2. Resident 4 and Resident 5 did not have interventions regarding inability to use call lights in their care plans; and, 3. Resident 10 did not have a call light that accommodated his special needs These failures had the potential to result in the residents not attaining their highest practicable physical, psychosocial and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate was below 5% or greater when the error rate was 25.81% based on eight medication errors out of 31 opportunities observed during a medication administration observation for four out of six residents (Resident 20, Resident 36, Resident 101, and Resident 25). This failure resulted in medications not given in accordance with the prescriber's orders or manufacturer's specifications and had the potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and maintain an effective infection prevention and control program for a census of 49 residents when a shared blood pressure (BP) cuff was not cleaned and sanitized properly in between resident use. This failure resulted in increased risk for cross-contamination (transfer of bacteria from one person, object, or place to another) and may cause infections among residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure five residents out of a census of 49 (Resident 201, Resident 29, Resident 31, Resident 12, and Resident 44) were treated with dignity and respect when: 1) Resident 201's urinary catheter bag was not covered by a dignity bag; and, 2) RNA 1 and RNA 2 were standing up when assisting to feed Resident 29 and Resident 31; and, 3) Resident 12 and Resident 44 were not asked if they had a preference on using clothing protectors during their meals. These failures placed Resident 201, Resident 29, Resident 31, Resident 12 and Resident 44 at potential risk of diminished self-esteem and feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the comprehensive care plan for two of 49 sampled residents (Resident 255 and Resident 10) reflecting the residents' current health status and needs when: 1. Resident 255 's care plan was not updated for self-administration of medications; and, 2. Resident 10's care plan was not updated for wound dressings on his hands. These failures had the potential to result in Resident 255 and Resident 10 receiving outdated and not person-centered care placing the residents at risk for not meeting their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan on wound care interventions for 2 of 6 sample residents (Resident 2 and Resident 4). This failure to develop and implement a comprehensive person centered care plan on specific wound care needs had the potential for Resident 2 and Resident 4 to receive inaccurate and inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hemodialysis (HD- treatment that filters waste from the blood when kidneys are not working) services were provided per facility policy for one of three sampled residents (Resident 1), when Resident 1 missed four outpatient hemodialysis appointments due to lack of transportation services and the physician was not notified of missed HD appointments. This failure resulted in Resident 1 going to the hospital for potential fluid retention increasing the risk for respiratory decline.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate indwelling catheter (a tube placed in the body to drain and collect urine from the bladder) care and services for one of 4 sampled residents (Resident 1) when Resident 1 did not have physician order for indwelling catheter care nor a catheter change for several months after admission to the facility. This failure had the potential to contribute to Resident 1's development of a urinary tract infection (UTI, a clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to assure professional standards of care were followed when: 1. Resident 15, 19, and 29's oxygen tubing (a device that delivers extra oxygen through a tube into your nose) and humidifiers (devices used to humidify supplemental oxygen) were not labeled, dated and changed. 2. Resident 11's physician order for 1:1 (one on one) feeding assistance with meals was not carried out as ordered. 3. Resident 28's physician order for a plate guard (an adaptive device that prevents food from accidentally being pushed off the plate while eating) with all meals was not carried out as ordered. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and kept confidential multiple residents medical records. This failure had the potential to exposed multiple residents health information by persons not involved in the residents care, for a facility census of 51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits of the Medication Administration Record (MAR) and Controlled Drug Record (CDR) for three residents (Residents 9, Resident 28, and Resident 296) did not reconcile to indicate they were given to the residents. 2. Implement a system to accurately document and secure emergency medications (E-Kit). These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility had a 12.82% error rate when five medication errors out of 39 opportunities were observed during a medication pass for three of six sampled Residents (Residents 9, 21, and 30). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 30) was free of a significant medication error when Resident 30 missed 25 doses of Brovana (generic name aformoterol tartrate, a medication to treat breathing problems) when nursing staff did not know to check for it in the medication storage room refrigerator. This deficient practice had the potential to result in breathing complications and worsening of Resident 30's clinical condition.

Inspectors wroteBased on observation, interview and record review, kitchen staff failed to demonstrate appropriate competencies to carry out kitchen sanitation when: 1. Staff were unable to show the correct procedure for testing of sanitation solution buckets, and 2. Staff did not test dishwashing sanitation at the plate level, which was necessary to ensure adequate sanitation had occurred. These failures had the potential of leading to food borne illness for the 49 residents eating facility prepared food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food storage, preparation and cleaning areas were in accordance with professional standards for food service safety when: 1) Foods that had been opened previously were not tightly closed, 2) A dirty fan was turned on and blowing onto clean plate guards, 3) Dishwash sanitizer solution test strips were not correct for solution type (to ensure sanitation occurred), 4) Resident refrigerator/freezer containing food for residents had food products marked with a room number but missing resident name. This failure had the potential to cause food borne illness in 49 of the 51 facility residents that received facility prepared foods.

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent was obtained (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) on the use of psychotropic medication (drugs that affect a person's mental state) for one of 14 sampled residents (Resident 447). This failure decreased the facility's potential to ensure Resident 447 and responsible party (RP) were aware of the risks, benefits, and alternatives of treatment offered to them.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure resident assessments were accurate for one resident (Resident 15) out of nineteen sampled residents. This failure had the potential to establish incorrect baseline data and treatment for Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan on the use of a BiPAP ( a noninvasive ventilator that helps people breathe by delivering pressurized air into their airways through a face mask) machine for 1 of 19 sampled residents (Resident 10). This failure to develop a care plan on the use of a BiPAP machine had the potential for Resident 10 to received inaccurate and inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored correctly for a census of 51 residents, when a medication cart (a lockable cabinet on wheels that stores drugs and supplies) and a treatment cart (a lockable cabinet on wheels that stores drugs and supplies) were unlocked and unattended. These failures had the potential for drug diversion and drug misuse.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a resident (296) the appropriate nutritive profile matching the physician prescribed renal diet when potatoes were served. This failure had to potential to lead to confusion regarding diet restrictions for the resident, as well as lead to heart issues due to the high potassium content from the meal provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the infection prevention and control program guidelines and practices were maintained for a census of 51, when Certified Nursing Assistant 5 (CNA 5) was observed taking trash from one resident room to another and allowed trash bags to rest against her clothing. This failure had the potential to result in transmission and spread of infection for a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to administer a pneumococcal vaccine (immunization [process of becoming protected against a disease through vaccination] against pneumonia [an inflammatory condition of the lung]) for one of 19 sampled residents (Resident 15). This failure placed Resident 15 at an increased risk for illness that the vaccine could have prevented or decreased the severity of symptoms.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the reach-in freezer in a safe operating condition when ice build-up was found on the freezer ceiling. This had the potential of leading to food borne illness for the 49 residents receiving facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal the need for help) was accessible for one of 19 sampled residents (Resident 297), when Resident 297 was not physically able to use the type of call light provided. This failure had the potential to result in unmet resident needs and delayed staff response.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow guidelines for infection control practices for two of five sampled residents, Resident 4 and Resident 5 when: 1. Social Services Assistant (SSA) did not wear the required Personal Protective Equipment (PPE) before entering Resident 4's room; and 2. Certified Nursing Assistant 1 (CNA 1) did not wear the full required PPE before entering Resident 5's room. This deficient practice had the potential to spread infections among residents, staff and visitors.

Inspectors wroteBased on interview and record review, the facility failed to coordinate with the PASRR (Preadmission Screening And Resident Review, for residents with a mental disorder) evaluation program for one of three sampled residents (Resident 1) when Resident 1 had positive results on Level I screening which required Level II screening to identify the specialized services required by the resident. This failure placed Resident 1 at risk for not receiving rehabilitative services that the resident needed.

Inspectors wroteBased on interview and record review, the facility failed to maintain reasonable accommodation of resident needs and preferences for one resident (Resident 1) in a facility census of 48 when Resident 1's personal items were moved beyond her reach and complaints about her roommate were not addressed timely to ensure her dignity and well-being. This failure resulted in Resident 1 feeling distressed and upset.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to protect one of three sampled residents (Resident 1's) right to be free from abuse when a fellow resident took her personal belongings. This caused Resident 1 to be feel distressed, emotionally unsafe, and unable to sleep.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse and theft/misappropriation of property to local, state, and federal agencies within 24 hours for one resident (Resident 1) in a facility census of 48, when a friend of Resident 1 reported to the Social Services Director (SSD) an allegation of Resident 1 feeling frightened and unsafe. This failure resulted in Resident 1 to remain fearful when the facility delayed reporting and investigating.

Inspectors wroteBased on interview and record review, the facility failed to implement its Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Policy for one resident (Resident 1) in a facility census of 48 when the facility failed to ensure Resident 1's allegation of abuse and mistreatment was timely and thoroughly investigated. This failure to protect one of their vulnerable residents and provide a safe environment caused Resident 1 to feel emotionally unsafe and fearful.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents (Resident 2 ' s) right to privacy was protected when the privacy curtain did not fully surround the resident's bed and provide her with full privacy. This failure resulted in Resident 2 to have felt exposed and subjected to bright lights that blinded her from the bathroom.