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 Cedars Health Center during CMS and state inspections, most recent first.
Failure to Follow Care Plans for Personal Hygiene and Grooming: The facility did not implement care plan interventions for personal hygiene for multiple residents. A resident who preferred to be clean-shaven was observed with facial hair, another resident had long fingernails with debris despite a care plan for nail care, and other residents were observed with unaddressed facial hair and dirty nails. Staff and the DON/ADON confirmed that these grooming needs were part of the residents’ care plans and were not completed as planned.
Failure to Provide Nail Care and Shaving: Multiple residents who needed assistance with ADLs were observed with long, dirty fingernails and/or unshaved facial hair. Staff interviews confirmed that nail care and shaving were expected to be completed during bathing, but the care was not provided for several residents, including residents with cognitive impairment and diagnoses such as dementia, MS, encephalitis, and Alzheimer’s disease.
Dirty Wheelchair Not Maintained in a Sanitary Condition: A resident with Alzheimer's disease and severe cognitive impairment was observed sitting in a wheelchair in the lobby with the lower frame and left wheel covered in an orange dried substance. A CNA confirmed the wheelchair was dirty and appeared to have dried food on it, and the ADM stated staff were expected to keep resident equipment clean to provide a sanitary environment.
Failure to monitor refrigerated medication temperatures in the rehab unit medication refrigerator was identified during observation and record review. The facility policy required daily temperature checks and documentation, but the log had multiple missing entries across the month. An LPN stated the checks were scheduled for each night shift, and the DON and ADM confirmed the facility failed to monitor and document the refrigerator temperatures as required.
A resident with chronic health conditions and moderate cognitive impairment was left unattended and strapped in a facility transport van for approximately two hours after returning from a medical appointment. The resident was found hot, thirsty, weak, and emotionally distressed, having missed hydration and care, after staff failed to remove her from the van. The Transportation Aide admitted to being distracted and not following required procedures, resulting in neglect of the resident's care and safety needs.
A resident with dementia and severe cognitive deficits was able to exit the facility unsupervised after staff failed to accurately assess and identify elopement risk during admission. The responsible party did not disclose the resident's history of wandering, and staff did not directly ask about prior elopement, resulting in the resident being able to leave through an automated door in a wheelchair.
A resident's right to a safe and comfortable environment was compromised when her wheelchair's right armrest was found damaged, exposing rough foam and metal. Despite the resident's complaints, no action was taken until a CNA reported it to maintenance. The Director of Therapy and OT staff were aware of the issue but failed to document the resident's refusal to replace the wheelchair and her preference for repair. The facility's administrator acknowledged the oversight in documentation and repair, leading to the deficiency.
A facility failed to accurately submit MDS information for a resident due to a medication misclassification. The RN MDS Coordinator mistakenly entered Ozempic as insulin, leading to incorrect data submission. The resident, with Type 2 diabetes and dementia, was inaccurately documented as receiving insulin injections. This error was confirmed by the MDS Coordinator and Administrator.
The facility failed to implement comprehensive care plans for two residents. One resident requiring enhanced barrier precautions did not receive proper care as an LPN failed to wear a protective gown during PEG tube care. Another resident needing assistance with ADLs was found unkempt, with long nails and facial hair, indicating the care plan was not followed. The deficiencies were confirmed by facility staff.
A resident with unspecified dementia was found unkempt, with greasy hair, long nails, and facial hair, indicating a failure to provide necessary ADL assistance. Despite being scheduled for regular showers, staff interviews confirmed the resident had not received proper grooming care. The facility's policy required aides to perform these tasks, but observations and staff admissions revealed a lapse in adherence to these responsibilities.
A medication error rate of 7.14% was identified in an LTC facility when an LPN administered incorrect dosages of MiraLax and Flonase to a resident with Allergic Rhinitis and Constipation. The LPN gave one capful of MiraLax instead of two and allowed the resident to self-administer one spray of Flonase per nostril instead of two, contrary to the physician's orders. The DON confirmed the orders were not followed as expected.
A facility failed to follow Enhanced Barrier Precautions during the care of a resident with a PEG tube. An LPN did not wear a protective gown as required, despite the presence of a precaution sign and the facility's policy. Interviews confirmed the oversight, which was attributed to nervousness, although the LPN was aware of the requirements.
A resident with dementia was aggressively transferred by a CNA, resulting in bruising. The incident was captured on a ring camera, leading to the CNA's termination. The facility failed to protect the resident from physical abuse, violating its policy on abuse prevention.
Failure to Follow Care Plans for Personal Hygiene and Grooming
Penalty
Summary
The facility failed to implement a comprehensive care plan for personal hygiene and grooming for five sampled residents. The deficiency was identified through observation, resident, staff, and family interviews, record review, and facility policy review. The facility policy stated that it was the policy of the facility to develop and implement a comprehensive person-centered care plan, and staff interviews confirmed that personal hygiene interventions such as facial hair removal and nail care were expected to be followed as part of the care plan. Resident #4 had a care plan for assistance with ADLs related to a recent hospitalization for left femur fracture, total hip arthroplasty due to autoimmune encephalitis, falls, confusion, weakness, and need for staff assistance with dressing, bathing, personal hygiene, transfers, and wheelchair mobility. The resident was observed lying in bed with approximately 1/8 inch gray facial hair, and the sister-in-law stated he liked to be clean-shaven. CNA #3 later confirmed the face was not shaved and the facial hair was long. The ADON stated that if the resident was supposed to have a shaven face and did not, the care plan was not followed. Resident #10 had a care plan intervention to check nail length and trim and clean nails on bath day and as necessary, but his fingernails were observed to be approximately one-half inch long with brown substance underneath both hands. The resident stated staff did not offer to do his fingernails during the shower, and CNA #1 confirmed the nails were long with brown substance underneath and should have been taken care of the prior day. Resident #34 was observed with long gray facial hair on the chin, sides of the face, and above the lip, and she stated she did not like facial hair; CNA #6 confirmed the finding. Resident #60 was observed with a patch of facial hair on both upper corners of the lip, stated she did not like it and wanted it removed, and CNA #2 confirmed the facial hair should have been addressed during shower care. Resident #92 had long dirty fingernails with thick black substance underneath and long gray hairs on the chin; CNA #6 confirmed the findings, and the MDS Nurse stated nail care and female facial hair would be addressed as part of personal hygiene during bathing and routine care.
Failure to Provide Nail Care and Shaving
Penalty
Summary
The facility failed to provide nail care and shaving for five sampled residents who were unable to complete these activities independently. The facility policy stated that residents unable to carry out activities of daily living would receive the necessary services to maintain grooming and personal hygiene. Observations, interviews, and record review showed that Resident #4 was observed unshaved with facial hair present, and his sister-in-law stated he likes to be clean shaved. CNA #3 confirmed his face was not shaved, and the ADON stated it was her expectation that staff shave him and that he was supposed to have a shaven face. Resident #10 was observed with fingernails approximately one-half inch long with a brown substance underneath. He stated no one offered to take care of his nails, and CNA #1 confirmed the nails were long and dirty and should have been trimmed and cleaned. The RN Supervisor stated nail care was supposed to be completed during shower time and acknowledged that leaving the nails long and dirty could allow him to scratch himself or someone else. Resident #34 was observed with visible gray facial hair on her chin, sides of her face, and above her lip. She stated she had been told someone would shave her face but could not find a razor, and CNA #6 confirmed she needed to be shaved and that aides were responsible for shaving facial hair during bathing. Resident #60 was observed with patches of facial hair on her upper lip, and she stated she did not like it and that staff never offered to remove it. CNA #2 confirmed the facial hair and stated it should have been taken off during the resident’s scheduled shower time. Resident #92 was observed with long fingernails with thick brown substance under the nails and long gray hairs on her chin. CNA #6 confirmed the long dirty nails and facial hair and stated aides were responsible for addressing nail care and facial hair with bathing. RN #1 and the Administrator both stated that nail care and facial hair removal were expected to be addressed during bathing or when needed.
Dirty Wheelchair Not Maintained in a Sanitary Condition
Penalty
Summary
The facility failed to maintain a wheelchair in a clean and sanitary manner for one resident using a mobility device in house 600. On observation, the resident was sitting in her wheelchair in the front lobby area, and the lower wheelchair frame and left wheel were covered in an orange-colored dried substance. A CNA later confirmed that the wheelchair was dirty and covered in a dried substance she thought was food, and stated it was everybody's responsibility to ensure resident equipment was clean. The Administrator stated her expectation was for staff to ensure resident equipment was kept clean to provide a sanitary environment. The resident had been admitted with a diagnosis of Alzheimer's Disease and had a BIMS score of 3, indicating severe cognitive impairment.
Failure to Monitor Refrigerated Medication Temperatures
Penalty
Summary
The facility failed to monitor refrigerated medications for proper temperature control in one of 11 medication refrigerators, specifically the refrigerator in the rehabilitation unit medication storage room. The facility policy titled, "Storage of Medication Requiring Refrigeration," dated 4/2025, required medication and biological refrigerators to be maintained between 36 and 46 degrees F and to have temperatures monitored daily with the date, time, and signature documented on the temperature log. During observation and record review, the Medication Refrigerator Temp Logs for November 2025 showed multiple missing entries, including 11/1/25, 11/2/25, 11/4/25, 11/5/25, 11/7/25, 11/8/25, 11/9/25, 11/10/25, 11/11/25, 11/13/25, 11/17/25, and 11/19/25. An LPN stated the refrigerator temperatures were scheduled to be monitored each night shift. The DON confirmed the facility failed to monitor and document the refrigerated medication temperatures, and the ADM also confirmed the failure to ensure proper and safe medication storage by not monitoring and documenting the refrigerator temperatures.
Resident Left Unattended in Facility Transport Van
Penalty
Summary
A facility failed to ensure a resident's right to be free from neglect when a resident was left unattended and strapped in a facility transport van for approximately two hours after returning from a medical appointment. The Transportation Aide (TA) parked the van at the facility and went inside without removing the resident, who was unable to ambulate or call for help. The resident remained in the van, exposed to heat and without access to hydration, care, or supervision, until staff located her after her representative inquired about her whereabouts. The resident, who had diagnoses including Paroxysmal Atrial Fibrillation and Chronic Kidney Disease and a moderate cognitive impairment, was found to be hot, thirsty, weak, and emotionally distressed upon being discovered. She had urinated on herself, her face was puffy, her eyes were red, and her hands were swollen. The resident expressed fear and anxiety during the incident, stating she thought she might die and was afraid she would be left on the bus overnight. Staff interviews confirmed the resident's physical and emotional distress upon her return to her room. The TA admitted to being distracted by work-related concerns and failing to ensure the resident was safely returned to her room. The facility's policy required that residents be protected from neglect, and staff interviews, including those with the DON and Administrator, confirmed that the resident's care and safety needs were not met during the two-hour period she was left unattended in the van. The incident was determined to be Immediate Jeopardy and Substandard Quality of Care due to the facility's failure to provide necessary care and supervision.
Removal Plan
- Hold a Quality Assurance (QA) meeting.
- Provide in-services with all staff.
- Complete a health assessment and monitoring for Resident #1.
- Notify reporting officials of the incident.
- Monitor through the QA program.
- Director of Nursing and Assistant Director of Nursing utilize End-of-Route Witness Audit Form to monitor both the vehicle walk-throughs and the completion of the End-of-Route Two-Person Checklist.
- Conduct monitoring.
Failure to Identify and Assess Elopement Risk Leads to Resident Exiting Facility Unsupervised
Penalty
Summary
The facility failed to accurately assess and identify the elopement risk for a resident with dementia and severe cognitive deficits, resulting in the resident exiting the facility unsupervised. Upon admission, the resident's elopement risk evaluation was completed and documented as zero for wandering and elopement, based on information from the responsible party who did not disclose a history of wandering. The responsible party later confirmed that the resident had a history of wandering at home, including leaving the house at night, and that alarms and cameras had been used at home to prevent such incidents. However, the facility staff did not directly ask about a history of elopement or attempted elopement as required by the assessment form, instead relying on general questions and the responsible party's lack of volunteered information. The incident occurred when the resident, who had limited mobility and was in a wheelchair, propelled himself outside through an automated sliding door. Staff discovered the resident outside and assisted him back into the building. Video surveillance confirmed the resident exited through the front doors unsupervised. At the time, staff believed the resident belonged in another department and did not initially recognize the elopement risk. Interviews with facility staff revealed that the admission nurse did not directly ask the responsible party the specific question regarding a history of elopement, as required by the facility's policy and assessment form. Instead, the nurse used a more casual approach, which resulted in the omission of critical information about the resident's history of wandering. The resident's Minimum Data Set indicated severe cognitive impairment, further underscoring the need for a thorough and direct assessment process.
Failure to Maintain Resident's Wheelchair in Good Repair
Penalty
Summary
The facility failed to ensure a resident's wheelchair was in good repair, compromising the resident's right to a safe and comfortable environment. The resident, who was admitted with a medical diagnosis of muscle weakness, reported that the right armrest of her wheelchair was damaged, with the leather covering missing and exposing rough foam and metal. Despite the resident's complaints to the nursing staff, no action was taken to address the issue until it was observed by a Certified Nurse Assistant (CNA) and reported to maintenance. Further interviews revealed that the Director of Therapy and Occupational Therapy (OT) staff were aware of the wheelchair's poor condition but failed to document the resident's refusal to replace the wheelchair and her preference to have the armrest repaired. The facility's administrator confirmed that the wheelchair should have been repaired and that staff should have documented discussions with the resident and her family regarding the wheelchair replacement. This lack of documentation and follow-up led to the deficiency in providing a safe and comfortable environment for the resident.
Inaccurate MDS Submission Due to Medication Misclassification
Penalty
Summary
The facility failed to accurately submit information into the Minimum Data Set (MDS) assessment system for one resident. The deficiency was identified through staff interviews, record reviews, and facility policy reviews. The facility's policy on conducting accurate resident assessments emphasizes the importance of documenting the resident's medical, functional, and psychosocial status accurately. However, the Registered Nurse MDS Coordinator mistakenly entered Ozempic, a medication prescribed to the resident, as insulin in the MDS assessment. This error occurred because of a misunderstanding by the MDS Coordinator, leading to inaccurate information being submitted into the MDS system. The resident involved in this deficiency was admitted to the facility in 2017 and has diagnoses including Type 2 diabetes mellitus and dementia. The resident's MDS assessment with an Assessment Reference Date of May 31, 2024, incorrectly indicated that the resident received insulin injections, which was not the case. The error was confirmed during interviews with the MDS Coordinator and the Administrator, who acknowledged that Ozempic is not an insulin and should not have been coded as such. The resident's Brief Interview for Mental Status (BIMS) score indicated severe cognitive impairment, which underscores the importance of accurate documentation for appropriate care management.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement a comprehensive care plan for two residents, leading to deficiencies in care. Resident #85, who required enhanced barrier precautions due to the presence of a PEG tube and Foley catheter, did not receive proper care as observed on August 6, 2024. An LPN entered the resident's room, washed her hands, and applied gloves but failed to wear a protective gown, which is a requirement of the enhanced barrier precautions. The LPN admitted to knowing the protocol but did not follow it due to nervousness. The RN Infection Preventionist confirmed that the LPN should have worn a gown to prevent the spread of infection, and the RN MDS Coordinator acknowledged the failure to adhere to the care plan. Resident #106, who needed assistance with activities of daily living, was observed to be unkempt, with unbrushed hair, facial hair, and long fingernails. An LPN confirmed the resident's unkempt state and the need for grooming. The MDS Coordinator verified that the care plan for ADL assistance was not followed for this resident. Resident #106 was admitted with a diagnosis of unspecified dementia, which may have contributed to the need for assistance with personal care.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for bathing, shaving, and nail care. The facility's policy on ADLs, dated October 2023, outlined that care and services should be provided for bathing, dressing, grooming, and oral care. However, an observation on August 5, 2024, revealed that the resident was unkempt, with greasy hair, gray facial hair approximately one-fourth inch in length, and long fingernails measuring approximately three-eighths inch in length. The resident was alert but confused, and the lack of grooming indicated a failure to adhere to the facility's ADL policy. Interviews with staff confirmed the deficiency in care. A Certified Nurse Aide (CNA) stated that the resident was scheduled for showers on Monday, Wednesday, and Friday during the 3-11 shift, but acknowledged that the resident did not appear to have been showered as scheduled. The CNA also confirmed that the resident needed shaving and nail care, which were responsibilities of the aides. A Licensed Practical Nurse (LPN) corroborated the observation that the resident was unkempt and required grooming. The Director of Nursing (DON) expressed that her expectations were for aides to include nail care and shaving on designated shower days. The resident, admitted on December 23, 2022, had a medical diagnosis of unspecified dementia, which further emphasized the need for consistent and attentive care.
Medication Error Rate Exceeds 5% Due to Incorrect Dosage Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 7.14% for two out of 28 medication opportunities involving a resident. The deficiency was identified during an observation of a medication pass conducted by an LPN, who administered MiraLax and Flonase to the resident. The LPN prepared and administered only one capful of MiraLax instead of the prescribed two capfuls, and allowed the resident to self-administer only one spray of Flonase per nostril instead of the prescribed two sprays. This deviation from the physician's orders was confirmed by the LPN during an interview, where she acknowledged the oversight and its potential impact on the resident's condition. The resident involved had been admitted to the facility with medical diagnoses including Allergic Rhinitis and Constipation. The resident's Medication Administration Record (MAR) indicated specific orders for Fluticasone Propionate nasal spray and MiraLax oral powder, which were not followed correctly during the medication pass. The Director of Nursing confirmed that the physician's orders were not adhered to and emphasized the expectation for nurses to verify the correct dosage on the MAR before administering medications.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not following Enhanced Barrier Precautions during a resident care treatment. Specifically, during the care of a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube, a Licensed Practical Nurse (LPN) did not wear a protective gown as required by the facility's policy. The facility's policy mandates the use of personal protective equipment, including gowns, during high-contact resident care activities to prevent the spread of infection. Despite the presence of an Enhanced Barrier Precaution sign on the resident's door, the LPN only wore gloves and did not don a gown before beginning the PEG tube care. Interviews with the LPN, the Registered Nurse Infection Preventionist, and the Director of Nursing confirmed that the LPN should have worn a gown in addition to gloves to comply with the Enhanced Barrier Precautions. The resident in question had been placed on these precautions due to the presence of a PEG tube and a Foley catheter, as indicated in their order summary report. The failure to wear a gown during the procedure was acknowledged by the LPN, who attributed the oversight to nervousness, despite being aware of the precautionary requirements.
Resident Abuse During Transfer
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who aggressively transferred a resident from her bed to a wheelchair. The incident was captured on a ring camera placed in the resident's room by her family. The video showed the CNA roughly grabbing the resident under her armpits and quickly transferring her, which resulted in bruising under the resident's left armpit and scattered bruising on both arms. The resident, who had dementia and required more assistance, was resistant to the transfer, and the CNA made a hasty decision to complete the transfer without waiting for help. The Administrator and Director of Nursing both reviewed the video and expressed shock and disappointment at the CNA's actions. The CNA admitted to being pressed for time and acknowledged that the transfer was rough, although she did not intend to harm the resident. The CNA was remorseful and recognized that she should have waited for assistance to ensure the resident's safety. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents' health, welfare, and rights, which was not upheld in this instance. The resident involved had severe cognitive deficits due to Alzheimer's Disease and Vascular Dementia, as indicated by a Brief Interview for Mental Status (BIMS) score of 03. The resident's representative, who monitored the room via the camera, reported the incident to the CNA Supervisor, leading to the CNA's termination. The police were also involved, and an officer reviewed the video, confirming the aggressive nature of the transfer. The facility's failure to prevent this incident highlights a deficiency in ensuring the safety and dignity of its residents.
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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 Tupelo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tupelo Community Care Center | 4.6 mi | ★★★★★ | 9 | 0 |
| Diversicare Of Tupelo | 5 mi | ★★★★★ | 11 | 0 |
| Sunshine Health Care, Inc | 13.2 mi | ★★★★★ | 0 | 0 |
| Pontotoc Nursing Home | 13.8 mi | ★★★★★ | 0 | 0 |
| Pontotoc Health & Rehab Center | 14.7 mi | ★★★★★ | 3 | 0 |
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