Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Manor Nursing Home during CMS and state inspections, most recent first.
A facility failed to provide a dignified eating experience for six residents in the ADR when their plated meals remained on serving trays while they ate. CNAs confirmed the practice occurred during multiple meal observations, and the DON acknowledged that eating a plated meal off a tray may not be dignified. Residents in the main dining room did not eat with their plates left on trays.
Unsafe hallway transport of residents: Staff transported one resident in a wheelchair with a foot not properly positioned on the pedals and another resident seated on a walker instead of a wheelchair. The residents had significant mobility and medical needs, including severe cognitive impairment, scoliosis, COPD, and shortness of breath. Staff acknowledged the improper transport methods, and the DON stated residents seated on walkers should not be pushed.
Delayed Call Light Response: Two residents reported waiting 20 to 30+ minutes for call lights to be answered, including while needing help to use the bathroom. One resident had heart failure, impaired mobility, and moderate cognitive impairment; the other had Parkinson’s disease and required assistance with transfers and toileting. Resident council minutes also described waits of 30 to 45 minutes, lights being shut off without staff returning, and concerns that the facility was short of help. Staff and leadership could not explain how the call light system notifications related to the 15-minute response expectation.
A facility failed to provide a resident with the CMS Notice of Medicare Non-Coverage (NOMNC) in a timely manner. The resident's SNF services ended without documented communication regarding discharge and appeal rights. The NOMNC and SNFABN forms were signed after the required 48-hour notice period. The administrator admitted the absence of a policy for timely ABN provision.
A resident with an indwelling catheter was observed with the collection bag and tubing on the floor without a dignity cover, contrary to standard care practices. Staff interviews confirmed the expectation to keep the bag off the floor, but the facility's policy lacked this directive. A urine culture later showed yeast presence, indicating a potential infection risk.
The facility failed to document weekly wound assessments for a resident with burns and did not update the care plan to prevent further incidents. Another resident with a seizure disorder experienced multiple seizures without proper documentation of their duration or follow-up assessments. Staff interviews confirmed these lapses in documentation and adherence to facility policies.
The facility failed to ensure the safety of two residents, resulting in multiple falls and injuries. One resident experienced repeated falls due to improper transfer techniques and lack of required safety equipment, leading to fractured ribs and a hemothorax. Another resident had a facial bruise with no investigation or documentation of its cause, and the care plan did not address the injury.
The facility failed to treat two residents with dignity and respect. One resident with severe cognitive impairment was found with a bruise and reported rough treatment by staff. Another resident with intact cognition and multiple health issues reported staff complaints about her frequent urination and improper cleaning, leading to recurrent UTIs. The DON acknowledged the unacceptable behavior, and the Administrator referred to the Resident's Bill of Rights.
The facility failed to update Care Plans for three residents after significant incidents, including a bruise of unknown origin, burns from a coffee spill, and a choking episode requiring the Heimlich maneuver. Despite expectations for timely updates, the Care Plans were not revised to reflect these events.
Dignified Dining Not Maintained in Assisted Dining Room
Penalty
Summary
The facility failed to provide a dignified eating experience for six residents who ate their plated meals while the plates remained on serving trays in the Assisted Dining Room. During observations on 11/17/2025, 11/18/2025, and 11/19/2025, residents seated at tables in the ADR were served meals on trays and ate with their plates left on the trays. On 11/19/2025, two CNAs sat and fed two of the six residents while the meals remained on trays. The facility census was 50 residents, and the affected residents were identified as Resident #21, 32, 38, 41, 43, and 50. On 11/20/2025, a CNA confirmed that the six residents ate in the ADR on the three observed dates and that all of them ate their meals off plates that sat on serving trays. She stated that residents who ate in the main dining room did not have their plates on trays while they ate, and she said eating off trays seemed undignified. The DON also confirmed that residents in the ADR ate their plated meals off trays and stated that it may not be dignified to eat a plated meal that remained on a serving tray. The facility provided a Resident Rights document stating residents have a right to dignified existence and that the facility must treat each resident with respect and dignity.
Unsafe hallway transport of residents
Penalty
Summary
The facility failed to transport residents in the hallways in a safe manner for 2 of 2 residents reviewed for safety, Resident #17 and Resident #53. Resident #17’s MDS dated 10/7/25 documented diagnoses of other idiopathic scoliosis in the lumbar region, atrial fibrillation, and Alzheimer’s disease, with a BIMS score of 3 out of 15 indicating severe cognitive impairment. The resident was dependent on a wheelchair for mobility and dependent on staff for transfers. During an observation on 11/19/2025 at 1:44 PM, a CNA pushed Resident #17 in her wheelchair from a common area to the dining room for an activity while the resident’s right foot rested on a foot pedal and the left foot dropped between the pedals; as the chair was moved around a corner, the resident’s sock bumped along the ground. The CNA later stated she had not checked the resident’s feet before moving her and acknowledged the resident’s feet should have been on the pedals. Resident #53’s admission summary documented diagnoses of COPD, lumbago with sciatica, and spondylosis, and the baseline care plan directed staff to allow adequate rest periods during ADL tasks due to shortness of breath. The plan also indicated the resident required one staff member, a gait belt, and a 4-wheel walker for mobility. During an observation on 11/19/2025 at 1:26 PM, a CNA pushed Resident #53 from the shower room to her room seated on her walker for approximately 40-50 feet; the walker had no pedals and the resident’s feet were held up off the floor until the right foot lowered and skipped along the tile floor. The resident stated she did not feel safe being pushed on her walker and thought she should be in her wheelchair in the hall. The CNA confirmed she knew the resident should have been in her wheelchair instead of sitting on her walker, and the DON stated staff should not push a resident seated on a walker.
Delayed Call Light Response
Penalty
Summary
The facility failed to answer call lights within 15 minutes for 2 residents reviewed for call light response. Resident #5 had diagnoses including heart failure, adjustment disorder with depressed mood, benign prostatic hyperplasia with lower urinary tract symptoms, and pain. His MDS showed wheelchair use, dependence on staff for transfers and toileting hygiene, and a BIMS score of 11 out of 15. He reported that he needed staff help to use the restroom, that evening call lights had taken a half hour or more, and that this had happened within the past two days and on other shifts as well. Resident #49 had diagnoses including hypertension, Parkinson’s disease, anxiety and depression, and malnutrition. Her MDS showed use of a walker, partial/moderate assistance with transfers and toileting hygiene, and a BIMS score of 15 out of 15. She reported that staffing changes had made the past month more difficult and that it took 20 minutes for her call light to be answered that morning while she waited to go to the bathroom. Resident council minutes also documented reports of residents waiting 30 to 45 minutes for assistance, lights being shut off and staff not returning, and residents stating the facility was short of help. The facility did not provide documentation of follow-up on the concerns raised in resident council meetings, and staff and leadership interviews showed they were aware of call light response expectations but could not explain the timing of the system notifications or how they related to the 15-minute requirement.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) to a resident in a timely manner. The clinical record review revealed that the Skilled Nursing Facility (SNF) services for the resident began on 5/10/24 and ended on 5/28/24. However, the progress notes for 5/26/24 and 5/27/24 did not document any communication with the resident or their responsible party regarding the discharge from SNF services and the right to appeal. The NOMNC form and the SNFABN form were both signed by the resident's responsible party on 5/29/24, indicating a failure to meet the 48-hour notice requirement. The facility's administrator acknowledged the lack of a policy for providing the Advanced Beneficiary Notice (ABN) in a timely manner.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling catheter, which is crucial to prevent urinary tract infections (UTIs). The resident, who had a history of congestive heart failure, dementia, and a sacral pressure ulcer, was observed with the catheter collection bag and tubing resting on the floor without a dignity cover. This was noted during two separate observations on the same day, indicating a lack of adherence to proper catheter care protocols. Interviews with staff, including a registered nurse and the Assistant Director of Nursing, confirmed that the standard procedure to prevent UTIs involves placing the catheter bag in a dignity cover and ensuring it is kept off the floor. However, the facility's catheter care policy did not include these specific instructions, contributing to the oversight. A subsequent urine culture indicated the presence of yeast, suggesting a potential infection risk, although the report does not explicitly link this to the observed deficiency.
Documentation Failures in Wound and Seizure Assessments
Penalty
Summary
The facility failed to properly document assessments for two residents, leading to deficiencies in care. Resident #2, who had chronic congestive heart failure, renal insufficiency, and diabetes mellitus, suffered burns on her thighs after spilling hot coffee. The facility did not document weekly wound assessments for Resident #2 from 3/22/24 to 4/2/24, and the care plan was not updated to include interventions to prevent further incidents. Additionally, the wound assessments that were documented did not specify which wound they addressed, and multiple wounds were recorded on a single sheet, contrary to the facility's policy that each wound should have its own sheet for assessments. Interviews with staff confirmed the lack of proper documentation and care plan updates. Resident #3, who had cancer, hemiplegia, and a seizure disorder, experienced multiple seizures that were not properly documented. The facility failed to record the duration of the seizures and did not conduct follow-up assessments as required. On several occasions, Resident #3 was found unresponsive and exhibiting seizure-like activity, but the clinical records lacked detailed documentation of these events. Interviews with staff revealed that the expected documentation, including the length of the seizure and follow-up assessments, was not completed. The facility's seizure policy did not provide clear instructions on what to document after seizure activity, contributing to the deficiency. The Director of Nursing (DON) and other staff members acknowledged the lapses in documentation and the failure to follow the facility's policies. The DON confirmed that the facility's practice of documenting multiple wounds on a single sheet was not in line with the policy, and there was no explanation for the lack of documentation for Resident #2's wounds during the specified period. Similarly, the DON and other staff members admitted that the documentation for Resident #3's seizures was incomplete and did not meet the facility's standards. These deficiencies highlight significant gaps in the facility's documentation practices and adherence to care plans, impacting the quality of care provided to the residents.
Failure to Ensure Resident Safety and Proper Injury Investigation
Penalty
Summary
The facility failed to ensure the safety of Resident #5, who experienced multiple falls while being transferred by staff. On one occasion, Resident #5 fell while being transferred from her wheelchair to her recliner by a CNA, resulting in three fractured ribs and a hemothorax. The CNA did not use a gait belt as required by the care plan, and the wheelchair was not properly positioned, leading to the fall. Despite the resident's history of falls and the need for two-person assistance during transfers, the staff did not consistently follow these protocols, resulting in repeated injuries and hospitalizations for Resident #5. Additionally, the facility failed to determine the cause of a facial bruise on Resident #1. The bruise was first noticed by a CNA, but there was no immediate investigation or documentation of how the injury occurred. The bruise was not reported to the Director of Nursing (DON) until it had already started to heal, and no staff member could provide an explanation for the injury. The care plan for Resident #1 did not address the bruise, and the facility's skin assessment policy was not followed. These deficiencies highlight the facility's failure to provide adequate supervision and ensure a safe environment for its residents. The lack of proper transfer techniques, failure to use required safety equipment, and inadequate investigation and documentation of injuries contributed to the harm experienced by Residents #5 and #1.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with dignity and respect. Resident #1, who had severely impaired cognition due to Alzheimer's disease and other conditions, was found with a raised bruise on her forehead. Despite interventions to prevent further injury, a roommate reported that staff treated Resident #1 roughly and made dismissive comments about her appearance and care needs. This indicates a lack of respect and proper care for Resident #1's condition and dignity. Resident #5, who had intact cognition but required substantial assistance due to multiple health issues, reported that staff accused her of wetting her pants on purpose and complained about her frequent urination. Despite her medical condition requiring diuretic therapy, staff did not clean her properly, leading to recurrent urinary tract infections. A family member and another resident corroborated these claims, reporting that staff made derogatory comments and delayed attending to her toileting needs, causing her significant distress and embarrassment. The Director of Nursing acknowledged that staff behavior was unacceptable and contrary to the facility's expectations. The Administrator confirmed that the facility did not have a specific policy on dignity but referred to the Resident's Bill of Rights, which mandates treating residents with respect and dignity. The facility's failure to adhere to these standards resulted in the reported deficiencies.
Failure to Update Care Plans After Significant Incidents
Penalty
Summary
The facility failed to update Care Plans for three residents after significant incidents. Resident #1, who had severe cognitive impairment, sustained a bruise of unknown origin on her forehead. Despite multiple observations and health status notes documenting the bruise, the Care Plan was not updated to reflect this injury. The staff implemented an intervention to place a pillow against the wall, but this was not included in the Care Plan either. Resident #2, who had intact cognition, sustained burns on her thighs after spilling coffee on her lap. The Assistant Director of Nursing and the Director of Nursing both expected the Care Plan to be updated within 24 to 48 hours after the incident. However, the MDS Coordinator admitted to forgetting to update the Care Plan until prompted by the surveyor. The Care Plan was eventually updated to include the intervention of keeping the lid on coffee cups, but this was done weeks after the incident. Resident #4, who had severe cognitive impairment and required total assistance for all activities of daily living, experienced a choking episode that required the Heimlich maneuver. Despite this significant event, the Care Plan was not updated to reflect the choking incident. The Care Plan only included general instructions for assisting with intake and serving a pureed diet, without addressing the choking episode or any new interventions to prevent future occurrences.
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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.
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Nursing homes near Tipton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clarence Nursing Home | 8.2 mi | ★★★★★ | 0 | 0 |
| Mechanicsville Specialty Care | 11.2 mi | ★★★★★ | 4 | 0 |
| Crestview Specialty Care | 13.6 mi | ★★★★★ | 15 | 1 |
| Wilton Retirement Community | 13.9 mi | ★★★★★ | 2 | 0 |
| Wheatland Manor | 15.4 mi | ★★★★★ | 2 | 0 |
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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 July 2026) and official state health department websites.