Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Cedars The during CMS and state inspections, most recent first.
The facility failed to follow physician orders for multiple residents. One resident with atrial fibrillation received warfarin when it had been ordered held, and staff did not document physician notification after a critically high INR. Another resident with dementia missed repeated ordered daily weights, with refusals not documented in progress notes. A third resident with hypertension had multiple missed BP and pulse checks before receiving antihypertensive medications with hold parameters, despite orders requiring those measurements.
Failure to implement resident-specific fall prevention interventions for two residents. One resident with dementia, a fracture, repeated falls, and impaired safety awareness had a fall care plan that was not updated with alternative interventions or therapy recommendations after multiple falls. Another resident with dementia, Parkinson’s Disease, and muscle weakness was found on the bathroom floor with skin tears; documentation did not show whether the call light or motion detector was in use, toileting records were inconsistent, and anti-slip tape was not present in the bathroom despite fall-related interventions in the care plan.
Medication storage and labeling were not maintained for three residents. An RN observed an opened insulin vial with an open date, but also identified an eye lubricant and an inhaler in the med cart that had been opened without open-date labels. The affected residents had orders for insulin, eye lubricant for dry eye syndrome, and albuterol inhalant PRN, and facility policy required expiration dates to be identified and medication storage areas to be inspected for outdated and discontinued meds.
Two CNAs discussed a resident's personal feelings and history in the resident's presence during care, including comments about the resident not liking one of the CNAs and referencing the resident's past as a monk. The resident, who had major depressive disorder and other conditions, was not acknowledged during the conversation, which was observed by the family via a room camera. Staff and administration confirmed the conversation was unprofessional and did not align with the facility's policy on dignity and respect.
A resident with a history of hemiplegia and dementia fell and fractured their distal fibula after being left unattended in the bathroom, despite documented fall interventions. The facility's policy required that the resident not be left alone, but this was not adhered to, resulting in the incident.
The facility failed to properly label and store food items and ensure consistent hand hygiene, affecting all residents served by the kitchen. Observations revealed unlabeled and expired food items, and staff did not adhere to handwashing protocols. The Dietary Manager confirmed the need for proper labeling and hand hygiene, which were not followed according to facility policies.
A resident with severe cognitive impairment and on anticoagulants was transferred to the hospital without the required transfer form. Staff interviews confirmed that the form should have been completed and included in the resident's record, but it was not. Additionally, the facility's hospital transfer policy could not be located.
A resident with severe cognitive impairment and gastrointestinal issues did not receive appropriate care due to the facility's failure to follow physician orders for blood tests and medication management. Despite orders to hold Eliquis, a blood thinner, until further tests were completed, the medication was resumed without clarification, leading to a critical drop in hemoglobin levels and hospitalization. Interviews revealed a lack of protocol adherence and policy for managing GI bleeds.
An LPN failed to perform proper hand hygiene during wound care for a resident with a stage 4 pressure ulcer. The LPN did not wash hands or change gloves at necessary points, such as after removing the old dressing and before handling clean materials. The resident's care plan required specific wound care interventions, and the facility's policy mandated hand hygiene throughout the procedure.
The facility failed to provide respiratory care according to physician's orders for a resident with Alzheimer's, dyspnea, and heart failure. Observations showed the resident's oxygen tubing was not bagged as required, and oxygen was not consistently administered at the prescribed rate. Staff confirmed the protocol, but no care refusals were recorded, indicating non-compliance with the care plan.
A resident alleged physical abuse after experiencing severe back pain during care by two staff members, leading to a hospital diagnosis of a lumbar fracture. The facility's investigation was incomplete, lacking staff interviews and adherence to abuse prohibition policy.
A facility failed to implement person-centered interventions for a resident with pressure ulcers, resulting in deficiencies in care. The resident, with paraplegia and other conditions, developed a stage 4 pressure ulcer. Despite having a care plan, it lacked specific interventions for repositioning and did not address the resident's refusals of care. The facility also failed to implement wound clinic recommendations and did not perform weekly wound assessments as required by policy.
A resident's PICC line was found dislodged during morning care, and the facility failed to assess and document the incident as required. The CNA reported the dislodgement to an LPN, who noted dried blood on the line but did not remove the dressing or measure the line. The incident was reported to the physician, but no further action was taken, and no progress note was documented. The facility's policy required documentation of the catheter's condition and site appearance, which was not followed.
Failure to Follow Physician Orders for Medications, Weights, and Vital Sign Monitoring
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident with atrial fibrillation and anemia who had orders for warfarin dosing based on the day of the week. The resident’s INR was critically high at 5.1 on 8/11/25, and progress notes from 8/11/25 through 8/18/25 did not show that the physician was notified of the lab result. The MAR showed the resident was administered warfarin 5 mg on 8/12/25 even though the physician order indicated warfarin was not to be given on 8/11/25 and 8/12/25. A later INR on 8/18/25 was 4.6, and the NP then ordered vitamin K STAT and to hold warfarin for 2 days. The facility also failed to document and respond to repeated refusals of daily weights for a resident with hypertension, kidney and ureter disorder, and dementia. The resident had a physician order for daily morning weights to monitor for increased edema and weight gain, but 26 daily weights were missed between 5/30/25 and 8/22/25. Progress notes did not document refusals for the missed weights, and the resident’s care plan did not include daily weights. Staff interviews indicated refusals should have been charted in progress notes and reported so the DON could reapproach the resident, but the DON and Administrator were not aware the refusals and missed weights were occurring. The facility further failed to obtain and document required blood pressure and heart rate measurements before administering three antihypertensive medications to a cognitively intact resident with hypertension and hyperlipidemia. Orders for metoprolol succinate ER, isosorbide mononitrate, and losartan potassium each included hold parameters for low blood pressure or pulse, but the August 2025 MAR and vital signs records showed missing blood pressure and heart rate measurements on multiple mornings for these medications. One resident refusal was documented, but the remaining missing measurements were not recorded as required.
Failure to Implement Resident-Specific Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure resident-specific fall prevention interventions were implemented for two residents. One resident had dementia, a right upper arm fracture, a BIMS score of 9, required supervision or touching assistance with walking, and had multiple documented falls. The resident’s care plan identified a behavior of not waiting for staff assistance and a fall risk related to confusion, deconditioning, poor balance, and unawareness of safety needs. Although therapy evaluations were initiated after several falls, the care plan did not include alternative fall prevention interventions or therapy recommendations on multiple dates after subsequent falls, and the Administrator stated each fall should have been reviewed and alternative interventions considered after each fall. Another resident with moderate dementia, Parkinson’s Disease, and muscle weakness was found lying on the bathroom floor with three skin tears to the left elbow. The initial fall assessment documented poor balance and noted toileting by 3rd shift staff between 5:00 and 5:30 AM per the wife’s request, but the documentation did not include whether the call light was in reach or whether a motion detector was in use at the time of the fall. Observation showed anti-slip tape strips at the bedside and in front of the recliner, but not in the bathroom. The resident’s care plan included routine toileting, call light within reach, prompt response to requests, a motion sensor, and nonskid strips in front of the bed and recliner, while staff documentation showed toileting tasks were not consistently recorded during the early morning hours and the DON stated the resident was no longer supposed to be routinely toileted before 6:00 AM.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure medications were disposed of when expired and labeled with an open date after opening for 3 of 6 residents reviewed. During observation, an RN was preparing medications for a resident with diabetes and an opened vial of insulin was found with a handwritten open date; the RN stated the insulin should have been disposed of 30 days after the open date. In another observation, the RN examined open medications in the medication cart and identified that a resident’s eye lubricant had been opened without an open date label and another resident’s inhaler had been opened without an open date label. The RN stated all medications should be labeled with the date they are opened. Record review showed the resident with the insulin order had diabetes and was ordered insulin on a sliding scale four times daily. The resident with the eye lubricant had dry eye syndrome and an order for 1 or 2 drops to the affected eye as needed. The resident with the inhaler had a physician order for 2 puffs of albuterol inhalant every 6 hours as needed for wheezing, cough, or shortness of breath. Facility policies titled Medication Administration and Medication Storage indicated expiration dates should be identified and medication storage areas should be inspected routinely for outdated and discontinued medications.
Failure to Treat Resident with Dignity and Respect During Care
Penalty
Summary
Staff failed to treat a resident with dignity and respect during the provision of care. While providing care to a resident diagnosed with major depressive disorder, anxiety disorder, and a nontraumatic intracerebral hemorrhage, two CNAs discussed the resident's personal feelings and history in the resident's presence. The conversation included comments about the resident not liking one of the CNAs and referenced the resident's past as a monk, with remarks about expectations of peace and love. The resident was not acknowledged during this exchange, and the conversation was conducted in front of both the resident and a camera in the room, which was later reviewed by the family and facility administration. Interviews with staff and administration confirmed that the conversation was unprofessional and that neither CNA attempted to redirect or stop the discussion in the resident's presence. Other staff members interviewed indicated that discussing resident information or personal feelings in front of residents is considered disrespectful and should not occur. The facility's policy on resident rights, which was in effect at the time, stated that residents have the right to be treated with dignity and respect. The deficiency was identified following a complaint from the resident's family, who observed the incident via the room camera.
Failure to Follow Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that fall interventions were followed for a resident, identified as Resident B, who was at high risk for falls. On the morning of February 15, 2025, Resident B, who had a history of hemiplegia, hemiparesis, and dementia, was found on the bathroom floor after attempting to self-transfer onto the toilet. This incident occurred after a Qualified Medication Aide (QMA) assisted Resident B onto the toilet and then left the resident unattended, despite a care plan intervention added on February 12, 2025, which specified that Resident B should not be left alone in the bathroom. The incident resulted in Resident B sustaining a fracture to the distal fibula. The facility's policy on fall prevention required that the resident's fall risk and interventions be indicated on the Certified Nurse Aide (CNA) sheet, which was confirmed to include instructions not to leave Resident B unattended in the bathroom. Interviews with the Administrator and a CNA confirmed that the fall interventions were documented and accessible to staff, yet they were not followed, leading to the resident's fall and injury.
Deficiencies in Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, as well as consistent hand hygiene practices, affecting all 39 residents served by the kitchen. During an observation, a container of chopped lettuce with brown and yellow edges was found without a date, and similar issues were noted with grape tomatoes, polish sausage, and various vegetables in the freezer, all lacking open dates. Additionally, expired turkey was found in the cooler, and several other items, including ice cream and cheeses, were improperly stored without dates. The Dietary Manager confirmed that all food should be labeled and dated when opened. Hand hygiene practices were also found lacking, as observed when a dietary aide washed her hands for only 7 seconds before dishwashing duties, and another staff member failed to perform hand hygiene after leaving the kitchen to obtain water. The Dietary Manager stated that hands should be washed with soap and good friction for at least 20 seconds, especially when changing tasks or work areas. The facility's policies on safe food storage and hand hygiene were not adhered to, as confirmed by the Administrator.
Failure to Provide Required Hospital Transfer Information
Penalty
Summary
The facility failed to provide Resident 37 with the required transfer information during a hospital transfer. Resident 37, who had severe cognitive impairment and was on anticoagulants, was transferred to the hospital due to critical laboratory results. However, a hospital transfer form was not found in the resident's record for the date of the transfer. Interviews with staff, including an LPN and the Administrator, confirmed that a transfer form should have been completed and included in the resident's record, but it was not. Additionally, the Director of Nursing was unable to locate a facility hospital transfer policy.
Failure to Follow Physician Orders for High-Risk Medication
Penalty
Summary
The facility failed to ensure physician orders related to a high-risk medication, Eliquis, were clarified and followed for a resident with severe cognitive impairment and multiple health issues, including dementia and gastrointestinal hemorrhage. The resident was ordered to have specific blood tests (CBC and CMP) due to rectal bleeding, but these tests were not completed as ordered. Despite a physician order to hold Eliquis until further blood test results were available, the medication was resumed without the necessary clarification or completion of the required tests. This oversight led to the resident experiencing a critical drop in hemoglobin levels, necessitating hospitalization. The resident's medical record indicated multiple instances where lab results were either not obtained or not communicated effectively, leading to a lack of appropriate response to the resident's deteriorating condition. Interviews with facility staff revealed a lack of clarity and adherence to protocols regarding the management of high-risk medications in the context of a suspected GI bleed. The Director of Nursing was unable to provide a facility policy related to the care of residents with GI bleeds, highlighting a gap in the facility's ability to manage such conditions effectively.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident, identified as Resident 12, who was observed to have a stage 4 pressure ulcer on the right buttock. During an observation, an LPN was seen performing wound care without washing hands or changing gloves at critical points in the procedure. The LPN handled clean dressing materials without performing hand hygiene after removing the old dressing and cleaning the wound. Additionally, the LPN did not clean the scissors before using them with wound care products. Resident 12's medical history includes multiple sclerosis, type 2 diabetes without complications, and unspecified dermatitis. The resident's care plan required specific wound care interventions, including the use of Dakin's solution and proper dressing techniques. The facility's policy, dated 2017, outlined the need for hand hygiene and glove changes before and after each step of the wound care process. The Director of Nursing confirmed that the LPN should have adhered to these hygiene protocols during the procedure.
Failure to Provide Respiratory Care as Ordered
Penalty
Summary
The facility failed to provide respiratory care according to physician's orders for Resident 29. During observations, it was noted that the oxygen concentrator for Resident 29 was positioned near the bed with the tubing and nasal cannula lying on top of the concentrator, not contained in a bag, which is against the facility's protocol to prevent contamination. The Director of Nursing confirmed that the oxygen tubing should be bagged when not in use. Resident 29's medical records indicated diagnoses of Alzheimer's disease with early onset, dyspnea, and unspecified heart failure. The care plan required oxygen administration at 2 liters per minute while lying in bed, but observations showed that this was not consistently followed. Interviews with staff, including LPN 5, confirmed that the oxygen should be administered at the specified rate when Resident 29 was lying in bed, at bedtime, and during naps. However, there were no recorded occurrences of care refusal in the progress notes, indicating that the deficiency was not due to the resident's refusal. The facility's policy on oxygen administration, dated 9/10/24, reiterated the need to follow physician's orders, which was not adhered to in this case, leading to the deficiency.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of physical abuse involving a resident, identified as Resident N, who complained of severe lower back pain after being moved forcefully by two staff members. The incident was reported to the Indiana Department of Health, and a subsequent CAT scan revealed an acute compression fracture of the lumbar vertebrae, which required treatment. Despite the resident's report of the incident and increased pain to her nurse and the Director of Nursing, the facility's investigation lacked critical information, such as interviews with the staff involved in the care and other residents who might have had similar experiences. The facility's policy on abuse prohibition mandates an immediate and thorough investigation upon receiving an allegation of abuse, including ensuring the safety of the resident and preventing further potential abuse. However, the investigation into Resident N's allegations was not conducted thoroughly, as it did not include interviews with all staff members on duty at the time of the alleged incident or a list of such employees. The Administrator, who was on an extended leave of absence during the investigation, acknowledged that the investigation did not adhere to the facility's policy.
Failure to Implement Person-Centered Pressure Ulcer Care
Penalty
Summary
The facility failed to develop and implement person-centered interventions for a resident with pressure ulcers, leading to deficiencies in care. The resident, who had paraplegia, diabetes, and weakness, developed an unstageable pressure ulcer on her right buttock, which later progressed to a stage 4 ulcer. Despite having a pressure-relieving mattress and a care plan that included turning and repositioning every two hours, the care plan lacked specific interventions for repositioning and did not address the resident's refusals of care. The resident's care plan was not updated to reflect her refusals of wound treatments and repositioning, nor did it assess the reasons for these refusals, such as pain or time preferences. The facility also failed to implement wound clinic recommendations, such as increased monitoring of blood sugars and the use of a specialty mattress. The resident's TAR indicated refusals of wound treatments on specific dates, and there was a lack of follow-up notes or changes to the care plan to address these refusals. Interviews with the facility's administration and wound nurse revealed that weekly wound assessments were not completed according to facility policy. The care plan did not include interventions for refusals of wound care or education on the consequences of such refusals. Additionally, a new sacral wound identified by the wound clinic was not treated as ordered, although it eventually healed without treatment. The facility's policy required weekly wound assessments, which were not consistently performed.
Failure to Document and Assess Dislodged PICC Line
Penalty
Summary
The facility failed to assess and document a dislodged PICC line for Resident C, who was receiving intravenous medications for an infection. During morning care, a CNA noticed that Resident C's PICC line was out of her arm, and the resident was unsure how it happened. The CNA reported the incident to an LPN, who observed a small amount of dried blood on the PICC line but did not remove the dressing or measure the length of the line. The LPN reported the incident to the physician, but no further orders were given, and no progress note was documented regarding the dislodgement. Resident C's medical history included sepsis, metabolic encephalopathy, and diverticulitis with perforation and abscess. The resident was cognitively intact, with a BIMS score of 14, and required wound care following recent gastrointestinal surgery. The facility's policy required documentation of the length and intactness of the catheter tip, site appearance, and dressing when a PICC line was discontinued, but this was not done. The Director of Nursing acknowledged that the assessment and documentation should have been completed but were not.
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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 Leo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grey Stone Health And Rehabilitation Center | 5.5 mi | ★★★★★ | 17 | 0 |
| Ashton Creek Health And Rehabilitation Center | 5.5 mi | ★★★★★ | 0 | 0 |
| Heritage Pointe Of Fort Wayne | 5.7 mi | ★★★★★ | 4 | 0 |
| Bethlehem Woods Nursing And Rehabilitation | 7.2 mi | ★★★★★ | 6 | 0 |
| Lutheran Life Villages | 7.9 mi | ★★★★★ | 2 | 0 |
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