Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedars Healthcare Center during CMS and state inspections, most recent first.
Food service staff failed to follow hand hygiene and glove-change practices during meal service, including changing gloves without washing hands, touching a cell phone with a gloved hand, and moving from temperature documentation to meal service without hand hygiene. Multiple TCS foods were left out on prep tables and the meal service table without ice, with temperatures ranging from 48.9 F to 63.1 F. The main kitchen and dishroom also had damaged floors, a window above a prep table with peeling tape and dust/debris, and dirty flour containers with residue on the scoops.
Residents reported and audits confirmed repeated delays in call light response, with waits ranging from 15 to 60 minutes and some residents stating they waited 30 minutes to 2 hours for help. The facility’s policy required call lights to be answered as soon as possible and no later than 5 minutes, yet multiple residents described difficulty finding staff, especially at night, and staff interviews acknowledged the response-time problem.
The facility failed to report alleged abuse and an injury of unknown origin to the State Agency for three residents. One resident reported an LPN yelled at her and got in her face over pain meds, another resident with severe cognitive impairment was witnessed in a sexual act with his guardian and the report was delayed, and a third resident had an unexplained facial bruise that was not reported within the required timeframe.
Failure to Promptly Resolve a Resident Grievance: A cognitively intact resident with major depressive disorder and DM2 reported that prior grievances were not addressed. Record review showed a grievance about a nurse not administering all medications and not talking to the resident, but the form lacked the resident’s signature showing the resolution had been reviewed or approved. Staff stated a grievance was not resolved until the grievant signed it, yet the facility did not obtain that signature until about a month later.
Surveyors found multiple medications in medication carts and medication rooms that were not properly labeled with the resident’s name and open date, including a nasal spray, oxycodone suspension, Ozempic pen, Dulera inhaler, and an accessed TB vial. Staff also found loose or uncovered medications in a narcotic drawer and medication room, including a Dilaudid pill, a clonazepam tablet, and uncovered Tylenol tablets without an open or expiration date. RN, LPN, and DON interviews confirmed the items were not stored or labeled correctly.
The facility failed to maintain infection control practices during wound care, medication administration, and equipment disinfection. An RN did not follow EBP during wound care, brought a treatment cart into resident rooms, placed supplies on unclean surfaces, and did not perform hand hygiene between glove changes. An LPN also failed to perform hand hygiene between residents during med pass, and staff did not keep disinfectant wet long enough on a glucometer and vital signs equipment to meet the required dwell time.
Resident council grievances were not documented or resolved after concerns were raised in meetings. Five residents said they were not told how complaints were handled and did not get a response from the grievance official, while council minutes showed issues such as missing linens, a missing robe, privacy curtains, and a transition service complaint without documented resolution. The AD said he took notes at the meetings but did not write grievances from the complaints, and the SW consultant said no grievances were found.
A resident with a history of CVA-related hemiplegia, TBI, and anxiety reported that an LPN got in her face and yelled at her over scheduled pain medication, leaving her fearful and upset. A grievance documented the resident crying and requesting that the LPN no longer be assigned to her, but the LPN continued to provide care and administer meds for months afterward, with no documented psych-social follow-up after the incident.
A facility failed to administer and document medications correctly for two residents. One resident ordered Urea 40% cream for severe dry skin and hyperkeratosis was given a 20% product instead, and the nurse charted it as given before correcting the MAR after the error was found. Another resident with severe cognitive impairment and respiratory diagnoses missed a scheduled saline nasal spray dose because an LPN said the medication was not in the cart and did not stop the med pass to obtain it.
A resident with diabetes, neuropathy, and hemiplegia had wound care that was not carried out in accordance with orders. Staff observed a right forearm skin tear and a left arm abrasion/wound, but physician orders were not entered into the EMR in a timely manner, and the resident was seen with dated and undated dressings/wraps that were not consistently documented or initialed. Nursing interviews confirmed that new skin issues should trigger physician notification, wound team involvement, and proper documentation, but those steps were not completed as expected.
A resident with multiple chronic conditions and intact cognition used hearing aids, but they stopped working properly and were not followed up by audiology for about two months after the issue was identified. The care plan did not include a person-centered plan for bilateral hearing loss or hearing aids, and staff interviews showed the resident’s hearing aid needs were not consistently recognized or coordinated through the usual ancillary service process.
The facility failed to prevent unsafe smoking behavior and to maintain an appropriate smoking care plan for two residents. One resident was observed vaping in the dining room near other residents, including one on O2, despite a policy limiting smoking and e-cigarette use to designated outdoor areas. Another resident had a history of smoking marijuana and was identified as a smoker, but her smoking evaluation and care plan were not in place until the survey, even though staff described her as an independent smoker and noted she needed help with lighter use due to hemiplegia.
A resident with COPD and chronic respiratory failure was observed receiving oxygen at 2.5 LPM even though the physician ordered 3 LPM when in bed, while the MAR documented 3 LPM. Another resident with chronic respiratory failure, asthma, and sleep apnea had a concentrator ordered at 6 LPM continuously, but repeated checks showed the flow meter fluctuating between 6 and 8 LPM instead of staying steady. Staff interviews confirmed the concentrator settings should match the orders and that a faulty machine should not remain in use.
Pain Assessment and Care Planning Deficiencies: A resident with multiple cancer diagnoses and hemiparesis had daily pain that was observed and reported by the resident and her significant other, but the facility’s pain assessment did not fully document pain location, onset, duration, or the resident’s pain goal. The care plan addressed pain monitoring and medication effectiveness but did not include person-centered non-pharmacological interventions, and staff interviews showed inconsistent handling of the resident’s ongoing pain and PRN oxycodone use.
Delayed Replacement Dentures: A resident with multiple chronic conditions and intact cognition lost her upper and lower dentures and remained without replacement dentures for months. Dental records showed x-rays were taken for a replacement set, and staff knew the resident wanted dentures and had asked about their status, but follow-up was not completed in a timely manner. The resident was observed without dentures on multiple occasions, and interviews showed the RD, SSD, and other staff were aware of the issue but the replacement process had stalled.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with quadriplegia and hand contractures did not receive adequate skin care, leading to sores and skin breakdown. The facility failed to place absorbent materials in the resident's palms to prevent moisture buildup, despite the resident's care plan indicating the need for such interventions. Interviews revealed that the nursing staff did not consistently provide necessary preventative care, and the resident's family had to supplement hand hygiene. The facility lacked policies on contracture management and skin integrity.
Food Safety and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and dishroom. During meal service, dietary staff did not perform proper hand hygiene when changing tasks or changing gloves. One cook removed gloves and put on new gloves without washing hands, prepared food while wearing gloves, handled a cell phone with a gloved hand and did not change gloves afterward, and used the same gloved hand to open and close a drawer and then place cheese on a burger. Another cook wrote food temperatures in the temperature binder and then went to the food service line to begin meal service without washing hands. The dietary manager stated staff were expected to wash hands any time they changed tasks and when they changed gloves. The facility also failed to hold time/temperature control for safety foods at the correct temperature during meal service. Sliced lettuce, sliced tomato, sliced onion, shredded cheese, hard boiled eggs, turkey lunch meat, and shredded lettuce were left out on prep tables and by the meal service table without ice while they continued to be used. When temperatures were taken, the foods were measured between 48.9 degrees F and 63.1 degrees F, including lettuce at 60 degrees F, tomatoes at 60 degrees F, onion at 59 degrees F, shredded cheese at 53 degrees F, hard boiled eggs at 63.1 degrees F, turkey lunch meat at 56.1 degrees F, and shredded lettuce at 48.9 degrees F. The registered dietitian stated the food left out during meal service was thrown away, and the dietary manager stated the items normally should have been stored on ice during meal service. The main kitchen was also not maintained in good repair to provide cleanable surfaces. During the initial tour, the floor under the steam tables had several holes and gouges, and the dishroom floor had multiple holes, chips, large gouges, and a large crack running from under the dishwasher across the dishroom. A window above a food preparation table had fiberglass held with red duct tape, with the tape peeling and air coming in through a hole; dust and debris were visible on the inside of the window above the prep table. In dry storage, two wheeled flour containers were visibly dirty, and the scoops hanging on the outside of the containers had residue on them. On later observations, the same window condition, dust, debris, and dirty flour containers with residue on the scoops were still present. The dietary manager stated maintenance and administration were aware of the floor and that a plan to fix it was being developed, and he also stated the window issue was due to a recent storm and that he would clean the dust and debris from the window.
Delayed Call Light Response
Penalty
Summary
The facility failed to provide care to residents with respect and dignity by not responding to call lights in a timely manner for multiple sampled residents. The deficiency was identified for 15 residents, including residents who reported waiting 30 minutes, up to an hour, and in some cases one to two hours for staff assistance. Several residents stated that call lights were often answered so late that they forgot why they had called, had difficulty finding staff when needed, or had to wait while needing the bathroom. The facility’s own call light audits documented repeated delays well beyond the policy standard that calls for assistance be answered as soon as possible, but no later than 5 minutes. For one resident, the audit showed numerous call light activations not answered for 15 to 20 minutes, 20 to 30 minutes, 30 to 40 minutes, and 40 to 50 minutes over the review period. Similar audits for other residents showed repeated delays in the same ranges, including multiple instances of waits extending to 50 to 60 minutes. One resident reported that staff told him they were busy with other residents and that there was only one CNA on site at night. Staff interviews confirmed that response times were a concern. One CNA said a resident complained the most about slow call light response times. An LPN stated that an acceptable response time was around ten minutes, while the NHA acknowledged that the long response times had been brought to his attention and that he was aware of the problem. The report also noted that the NHA was newly employed within the last 30 days and said he needed to discuss the issue with QAPI before making plans for remediation.
Failure to Timely Report Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to report alleged abuse and an injury of unknown origin to the State Survey and Certification Agency in accordance with state law for three residents reviewed for abuse. The report states the facility did not ensure an alleged verbal abuse incident involving a cognitively intact resident was reported, did not ensure an alleged sexual abuse incident involving a resident with severe cognitive impairment and a traumatic brain injury was reported in a timely manner, and did not ensure an injury of unknown origin involving a resident with severe cognitive impairment was reported within the required timeframe. For one resident, the record showed a grievance documenting that an LPN was in the resident’s face, yelling, while the resident cried over pain medication not being administered as ordered. The resident later stated the LPN had yelled at her, scared her, and continued to be assigned to her despite her request that he no longer be her nurse. The staff development coordinator and DON both described the interaction as involving raised voices and fear, but the incident was not reported to the State Agency as alleged verbal abuse. For another resident, CNA #10 witnessed the resident performing oral sex on the resident’s guardian in the bathroom. The facility’s investigation documented that the resident had severe cognitive impairment, a BIMS score of 4, and was assessed as unable to give sexual consent. The investigation also documented that the guardian later confronted the resident in an aggressive manner and that the court was notified and guardianship was suspended. The incident was not reported to the State Agency until 13 days after the witness observed it. For a third resident, CNA #2 noticed a bruise on the resident’s face and reported it to the nurse after asking the resident how it occurred. The resident did not explain the bruise. The facility’s investigation identified the bruise as an injury of unknown origin at the time it was first reported, but the facility did not report it to the State Agency until the next day, more than 24 hours after it was first noticed.
Failure to Promptly Resolve a Resident Grievance
Penalty
Summary
The facility failed to make prompt efforts to resolve a grievance for one resident. The grievance policy stated that all grievances and complaints would be investigated and corrective actions taken, but the policy did not include a specific timeframe for completing the grievance process or informing the resident of the findings. Resident #33, who was cognitively intact with a BIMS score of 15 and had diagnoses including major depressive disorder and type 2 diabetes, reported that several grievances filed months earlier were not addressed. Record review showed a grievance completed by the ADON on 5/11/26 stating the resident believed a nurse was not administering all medications and did not talk to him. The form documented that the DON contacted the nurse on 5/12/26 and that the resident should notify management if the issue happened again, but there was no resident signature showing the resolution had been reviewed with or approved by him. Staff stated a grievance was not considered resolved until the grievant signed it, and the DON described the process as meeting with the resident to determine the concern and complete the form. The facility later produced an updated grievance form with the resident’s signature obtained during the survey, about one month after the grievance was filed.
Unlabeled and Loose Medications Found in Medication Carts and Rooms
Penalty
Summary
The facility failed to ensure drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two medication carts and two medication rooms. Surveyors found that several resident medications inside labeled medication boxes were not labeled with the resident’s name or the date the medication was opened, including a fluticasone propionate nasal spray for one resident, an oxycodone oral suspension for another resident, an Ozempic injector pen for a third resident, and a Dulera inhaler for a fourth resident. An accessed multi-dose TB PPD vial in the Main unit medication room was also found without the date it was opened. Surveyors also found loose medications in the Broadway unit medication cart. One small white pill was found in the bottom of the narcotic drawer, and RN staff identified it as a Dilaudid pill that had not been administered as part of a dose. A medication cup containing a yellow clonazepam tablet was also found in the narcotic drawer without a resident name or date. In the Broadway unit medication room, an uncovered medication cup labeled Tylenol 500 mg contained 27 tablets and had no expiration date or open date. During interviews, RN and LPN staff acknowledged the items were not stored or labeled correctly and stated that labeling was important to prevent medication mix-ups and medication errors. Staff also stated that loose pills in the cart should not have been there and that the uncovered Tylenol tablets should have been covered. The DON and regional clinical resource confirmed that the individual medication containers should have been labeled inside their boxes and that loose or unlabeled medications in the cart were not expected.
Infection Control Failures During Wound Care, Hand Hygiene, and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infections. During wound care, an RN did not follow enhanced barrier precautions as described in facility policy and did not maintain clean working surfaces for dressing supplies. The RN wore a mask and gloves during dressing changes, but the treatment cart was brought into resident rooms, supplies were placed directly on the cart, bedside tables, and resident beds without a disinfected barrier, and the cart was not disinfected between rooms. The RN also handled supplies with gloved hands after touching other surfaces and did not perform hand hygiene between glove changes. The wound care observations involved three residents receiving treatment for wounds, including leg, gluteal fold, and sacral wounds. In one room, the RN began a dressing change with supplies scattered on the treatment cart and no barrier pad under the resident’s leg. In another room, the RN opened drawers with gloved hands, placed gauze on the bedside table without disinfecting it, and later changed gloves without performing hand hygiene. The RN also used gauze on a wound in a manner described in the report as not hygienic, and supplies were repeatedly placed on surfaces that had not been cleaned or disinfected. The facility also failed to ensure hand hygiene was performed appropriately between residents during medication administration. An LPN administered medications to one resident and then entered another resident’s room to prepare to measure blood glucose without performing hand hygiene after leaving the first room. In addition, staff did not allow disinfectant wipes to remain wet for the required dwell time when cleaning a resident glucometer and vital signs equipment. The LPN wiped the glucometer for less than ten seconds, and an RN wiped a blood pressure cuff and pulse oximeter without leaving the surfaces wet for the two-minute dwell time identified in the report and facility interviews.
Resident Council Grievances Not Documented or Resolved
Penalty
Summary
The facility failed to ensure prompt action was taken when grievances were raised during resident council meetings. The grievance policy stated that all grievances and complaints would be investigated and corrective actions taken, but the policy did not include a specific time frame for completion of the grievance process. The resident grievance/complaint investigation report form was to be filed with the administrator within five working days, and residents were to be informed of findings and corrective actions within a blank time frame that was not filled in by the facility. During a group interview, five interviewable residents stated that grievances had been brought up in resident council meetings, but they were not informed how the issues were resolved and did not receive a response from the grievance official. They reported that several grievances had been filled out without being addressed and that they had to keep complaining until someone did something. Resident council minutes documented concerns about not having enough washcloths, a missing robe, privacy curtains, and a transition service complaint, but no resolution was documented for the April 2026 concerns. The activity director said he attended the meetings and took notes, but he had not written grievances from the April and May 2026 council complaints, and he did not follow up with a resident who wanted to speak privately. The social work consultant stated that no grievances were found from those resident council meetings.
Failure to Protect a Resident from Verbal Abuse and Remove the Involved LPN
Penalty
Summary
The facility failed to ensure one resident was free from verbal abuse and failed to remove the involved LPN from the resident’s care after the incident. Resident #56, who had diagnoses including right-sided hemiplegia and hemiparesis following cerebral infarction, a history of traumatic brain injury, and anxiety disorder, was cognitively intact with a BIMS score of 15. The resident reported that an LPN got in her face and yelled at her when she was trying to explain that her scheduled Oxycontin was not being administered as ordered, and she said the interaction scared her and caused depression and anxiety. The resident also stated she requested that the LPN no longer be her nurse, but he continued to care for her for months afterward. A grievance completed by staff documented that the resident was crying, that the LPN insisted the Oxycontin was PRN when it was actually scheduled, and that the LPN was in the resident’s face when staff arrived. The grievance also noted the resident requested that the LPN no longer be assigned to her because he had approached her in the same manner previously. Despite this, the LPN continued to be the resident’s assigned nurse for the next nine months, and the MAR showed he administered medications to her on 118 days after the incident. The record did not show psychological-social follow-up or monitoring for ongoing changes after the verbal abuse incident. Staff interviews showed the staff development coordinator saw the LPN about a foot from the resident’s face and hollering at her, and she said the resident was made fearful and cried. She stated she did not consider the incident abuse because the LPN did not hit the resident, and she allowed a 60 to 90 day trial without documentation of education or discussion with the LPN. The DON later stated she had directed that another nurse give the resident her medications and said she had not seen the grievance before the survey; she also said that if she had seen it earlier, she would have opened an investigation of verbal abuse.
Medication administration errors and unavailable ordered medication
Penalty
Summary
The facility failed to ensure medications were administered and documented in accordance with professional standards for two residents. One resident with hyperkeratosis of the feet, chronic pain, contractures related to rheumatoid arthritis, and significant dependence on staff for care had an order for Urea 40% cream to be applied to both soles twice daily. During observation, the nurse did not administer the cream when medication administration was occurring, and the resident stated staff were not always putting the cream on her feet as ordered. The resident’s feet were observed with thick yellow and white crusts covering the soles, and the resident said it had been months since staff had applied the cream. The nurse later found a container labeled with the resident’s name that contained Urea 20% cream rather than the ordered 40% cream. The nurse stated the container was the wrong strength, that the resident should have had the ordered 40% cream available, and that the medication had been charted as given even though it had not been administered. The MAR initially reflected administration at the time of observation, but the nurse changed the entry to not given after the discrepancy was identified. The pharmacist stated the 20% cream would not be as effective as the ordered 40% cream and that the pharmacy had never dispensed the medication for the resident. A second resident with diffuse traumatic brain injury, COPD, chronic respiratory failure with hypoxia, and severe cognitive impairment had an order for saline nasal spray twice daily for nasal congestion. During medication pass, the LPN stated the nasal spray was not in the cart and said she would have to go downstairs to get a replacement bottle, but she continued administering the other medications and did not pause to obtain the spray or seek help to ensure it was available. The LPN later stated the resident missed the dose because she did not administer the nasal spray. The DON stated she would have expected the nurse to pause and obtain the medication to administer immediately, and that the facility had nasal spray bottles in stock.
Delayed Wound Orders and Incomplete Skin Care Documentation
Penalty
Summary
The facility failed to ensure Resident #8 received wound treatment and care in accordance with physician orders and professional standards of practice. Resident #8 was admitted with diagnoses including type 2 diabetes mellitus with diabetic neuropathy and hemiplegia/hemiparesis following cerebral infarction, and the MDS showed mild cognitive impairment with dependence on staff for dressing, bed mobility, and transfers. On 6/9/26, the resident was observed in bed with a dressing on the right lower forearm dated 6/8/26 and an undated elastic wrap on the left forearm. The resident stated the right arm wound had been seen the prior day and that the left arm dressing had not been changed in a few days. Record review showed wound rounds on 6/4/26 identified a left arm abrasion and recommended treatment with abdominal pad, Kerlix, and elastic wrap daily and PRN, but those orders were not entered into the EMR until 6/10/26 and were dated effective 6/11/26. A progress note created during the survey documented a right forearm skin tear identified on 6/8/26 and treated with wound cleanser and medihoney, but there was no physician order in the EMR for that treatment on 6/8/26. The record also showed the right arm wound orders were not entered until 6/11/26, several days after the skin tear was identified. Interviews with nursing staff and the DON confirmed the breakdown in the process. An LPN stated that when a skin tear is identified, the nurse should complete a change of condition notification, notify the physician for orders, and notify the wound team. An RN stated he was not aware of the elastic wrap or the right arm skin tear and said the bandage under the elastic wrap was not dated or initialed. The DON stated that new skin tears should prompt notification of the physician and responsible party, and that bandages should be dated and initialed by staff providing care. The comprehensive care plan did not include interventions related to the resident's skin issues.
Failure to Ensure Timely Audiology Follow-Up for Hearing Aids
Penalty
Summary
The facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one resident who used hearing aids. The resident had diagnoses including major depressive disorder, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, epilepsy, generalized anxiety disorder, and chronic pain syndrome. The resident’s MDS assessment showed she was cognitively intact with a BIMS score of 15 out of 15, dependent on staff for toileting, showering, dressing, and transfers, and using hearing aids. The resident stated that her hearing aids stopped working for about two to four weeks and that the audiologist had not come to see her. She later said the hearing aids could be inserted and the battery functioned, but they did not connect or work properly, and they were still not functioning properly on another interview. The record showed an audiology consult order was in place, and an audiology note documented the resident was fitted, instructed on use, and told to follow up in one month for adjustments. However, the resident did not receive follow-up for approximately two months after the concern was identified. The resident’s comprehensive care plan did not include a person-centered plan for bilateral hearing loss or hearing aids. Staff interviews showed CNAs were unaware the resident used hearing aids, the RN said ancillary services were coordinated through social services, and the SSD and social services assistant acknowledged the hearing aids were not working properly and that the resident should have been on the audiology list to be seen earlier. The DON stated properly functioning hearing aids were important for understanding and communication.
Unsafe Smoking and Incomplete Smoking Care Planning
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and adequate supervision for two residents. One resident was observed vaping in the dining room while seated with other residents, including one who was using oxygen via nasal cannula. The resident took multiple puffs from an e-cigarette while remaining at the table with the other residents. The facility policy stated that smoking is only permitted in designated outdoor areas and that electronic cigarettes are permitted only in designated areas. The resident involved in the vaping incident had diagnoses including Wernicke's encephalopathy, major depressive disorder, emphysema, and nicotine dependence. His MDS assessment showed moderate cognitive impairment with a BIMS score of 9 out of 15, and he was independent with most ADLs. His smoking care plan, initiated earlier, identified him as a safe smoker who could smoke unsupervised, but it did not address e-cigarette use until the survey. During the survey, the care plan was updated to note that he had been seen using e-cigarettes in the dining room and that he was placed on supervised smoking. A second resident had a smoking care plan that was not initiated until the survey, despite records showing a history of smoking marijuana and reporting smoking while in the facility. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction, dysphagia, and vascular dementia. Her MDS showed a BIMS score of 12 out of 15 and substantial to maximal assistance with several ADLs. Although she was identified on the facility smoking list as a smoker and staff described her as an independent smoker, the record did not show a smoking evaluation completed at the time of the survey, and her smoking care plan was not in place until the survey.
Oxygen Therapy Not Delivered as Ordered and Concentrator Malfunction Noted
Penalty
Summary
The facility failed to ensure two residents receiving respiratory care were provided oxygen therapy consistent with physician orders and that one resident’s oxygen concentrator was functioning properly. Resident #53 had diagnoses including chronic respiratory failure with hypoxia, COPD, and dependence on supplemental oxygen. Although the physician ordered oxygen at 3 LPM via nasal cannula when in bed, the resident was observed lying in bed wearing oxygen that was set at 2.5 LPM. The resident stated she received 3 LPM and said the concentrator should be set to 3 LPM, but repeated observations showed it remained at 2.5 LPM while she was in bed. Record review showed nursing documentation on the MAR indicating Resident #53 was receiving oxygen at 3 LPM, while staff interviews confirmed the concentrator setting should match the order and that nurses should check the setting daily. The DON stated the resident would reset her own oxygen concentrator, especially after smoke breaks, and that this tendency had not been included in the care plan. The report also noted the resident’s oxygen care plan included administering oxygen as ordered. Resident #70 had diagnoses including chronic respiratory failure, chronic diastolic heart failure, asthma, obstructive sleep apnea, and dependence on supplemental oxygen. The physician ordered humidified oxygen at 6 LPM continuously via nasal cannula, and the MAR documented that amount. However, repeated observations over several days showed the oxygen concentrator flow meter fluctuating between 6 and 8 LPM rather than remaining steady at 6 LPM. The resident said staff had not mentioned the respirator was broken and that staff did not check the flow setting because they forgot, while staff and the oxygen company representative stated the flow meter should be steady and that a faulty machine should be removed from use.
Pain Assessment and Care Planning Deficiencies
Penalty
Summary
The facility failed to manage pain in a manner consistent with professional standards of practice, resident-centered care plans, and the resident’s goals and preferences for one resident reviewed for pain. The deficiency involved a resident with hemiplegia and hemiparesis following an intracranial hemorrhage and multiple cancer diagnoses, including breast cancer and secondary malignant neoplasm of the brain. The resident’s MDS showed she was cognitively intact, required extensive assistance with several ADLs, and was receiving both scheduled and PRN pain medication. During observation, the resident was lying in bed, drifting in and out of sleep, holding her right hand over her breast with curled fingers, and stated she did not want to speak because she was in pain. The resident and her significant other both reported daily pain, including pain in the right breast, knees, and throughout her body. The significant other said the resident frequently complained of pain and that oxycodone was often given late, with one report that she waited 40 minutes after requesting it. The resident stated her pain was usually above 6 out of 10, that her acceptable pain level was no longer acceptable, and that she was not aware she could have requested oxycodone to be scheduled earlier. Record review showed the readmission assessment documented chronic pain and intermittent pain, but it failed to specify pain locations other than back pain, failed to document when the pain started or how long it lasted, and did not include the resident’s pain goal. The pain evaluation also documented frequent pain over the prior five days and effects on sleep and daily activities, but again did not include a pain goal. The care plan identified pain related to breast cancer and hemiparesis and included monitoring pain, evaluating medication effectiveness, and notifying the provider if pain was ineffective, but it failed to include non-pharmacological approaches. Staff interviews reflected inconsistent understanding of the resident’s pain management needs, with some staff stating she should be on scheduled oxycodone because she consistently reported pain above her acceptable level, while the DON stated the resident was alert and oriented and capable of requesting PRN medication and that the physician determined when PRN medication should be changed to scheduled use.
Delayed Replacement Dentures
Penalty
Summary
The facility failed to ensure that one resident received timely assistance to obtain replacement dentures. Resident #7 had diagnoses including major depressive disorder, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, epilepsy, generalized anxiety disorder, and chronic pain syndrome. The resident was cognitively intact with a BIMS score of 15 out of 15 and required substantial to maximal assistance with personal and oral hygiene, including inserting and removing dentures and managing denture soaking and rinsing. Record review showed the resident lost her upper and lower dentures, which had been made in 2021. Dental notes documented that the resident was seen for a dental visit and x-rays were taken for a replacement set under a Once in a Lifetime program. A social services note documented that the dentist was trying to get another set of dentures made. The resident later told staff she had received a Medicaid letter approving replacement dentures and said she wanted dentures because they would help her eat, especially tough meat served by the facility. Despite these events, follow-up on the replacement dentures was not provided for six months. During that period, the resident was observed not wearing dentures on multiple occasions. Staff interviews showed that CNAs, RN, the RD, SSD, and social services assistant were aware of denture-related issues and that lost dentures were supposed to be reported for follow-up. The SSD stated the resident should not have gone without dentures and that the facility would pay if Medicaid did not cover them, but the resident still had not received replacement dentures at the time of the survey.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Inadequate Skin Care for Resident with Contracted Hands
Penalty
Summary
The facility failed to provide adequate skin care for a resident with contracted hands, leading to skin breakdown and sores. The resident, who was under 65 years old and diagnosed with quadriplegia, traumatic brain injury, and muscle contractures, was dependent on staff for mobility and at risk for pressure injuries. Observations revealed that the resident's hands were not properly managed to prevent moisture buildup, as there was no absorbent material placed in the palms to protect against skin breakdown. Interviews with the resident and their family indicated that the nursing staff did not consistently provide the necessary preventative care, resulting in sores and a foul odor due to moisture and lack of proper hygiene. The family had to supplement hand hygiene care, and the resident expressed that nurses did not place gauze or other absorbing materials between the contracted fingers or palms. The resident's care plan included interventions for contracture management, but the facility did not follow through with these measures effectively. Staff interviews revealed that the resident frequently refused to wear splints, and the family sometimes removed them, which contributed to the skin issues. The LPN acknowledged the lack of an order for absorbent materials in the resident's palms, and the DON was unsure if any attempts had been made to apply such materials. The facility was in the process of discussing the resident's care needs with the family, but at the time of the survey, no policies on contracture management and skin integrity were provided.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 553 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewater Health And Rehabilitation | 0.1 mi | ★★★★★ | 0 | 0 |
| Cambridge Care Center | 0.1 mi | ★★★★★ | 8 | 0 |
| Sierra Post Acute | 0.2 mi | ★★★★★ | 11 | 0 |
| Harmony Pointe Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Wheatridge Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.