Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aristacare At Cedar Oaks during CMS and state inspections, most recent first.
Unsafe Food Storage and Preparation Practices: The facility failed to maintain sanitary food storage and preparation practices in the main kitchen and ethnic specialty kitchen. Surveyors observed staff food stored with resident items, ice buildup and open packaging in the freezer, raw eggs stored above the bottom shelf, an empty sanitizer bucket in the dish machine area, dirty pans on drying racks, and a fruit item washed at the hand sink and prepared for service. In the ethnic specialty kitchen, the prep room door was propped open, a dirty fan was blowing into the area, and a DA used a flour bag to break up unrefined sugar with a hammer while the bag was on the floor.
Staff failed to follow infection control practices in several areas. In the kitchen, employees were observed handling food with bare hands, using improper hand hygiene, and washing hands incorrectly, while competency records were incomplete. During trach care for a resident with trach status, respiratory failure, a stage 4 pressure ulcer, and quadriplegia, two RNs did not perform hand hygiene before sterile glove use and initially provided care without the expected gown and mask. In the dining room, a CNA fed one resident while touching another resident and resumed feeding after leaving and returning without hand hygiene.
A resident who needed feeding assistance was observed being fed by a CNA while the CNA was standing, then later sitting behind and to the right of the resident. The CNA stated staff should be seated beside or facing the resident during feeding, and the LPN/UM and DON both stated staff should sit while feeding residents for dignity and to maintain direct eye contact during meals.
Call Bell Not Kept Within Reach: A resident with CVA-related hemiplegia/hemiparesis and moderately impaired cognition was observed twice with the call bell on the floor and out of reach, and the resident stated they would shout out or come out of the room for help instead of using the call bell. The care plan directed staff to keep the call light/call bell within reach, and the CNA, LPN, LPN/UM, and DON all stated the call bell should be in reach at all times.
Untimely Background and Reference Checks for Newly Hired Employees: The facility failed to follow its abuse screening policy for newly hired staff by not completing timely background checks for 4 employees and not completing timely reference checks for 3 employees. File review showed one CNA had no evidence of reference checks before hire, one RN had reference checks dated before employment, and one Housekeeper’s reference forms were not signed or dated; several background checks were completed after the employees’ dates of hire or were dated years earlier.
A resident with Asthma and ordered nebulizer treatments did not have those respiratory needs included in the ICCP. The resident was cognitively intact, had scheduled and PRN Ipratropium-Albuterol nebulizer orders for SOB/wheezing, and the care plan only addressed an ADL deficit related to fatigue. The LPN, UM, and DON all confirmed that Asthma and nebulizer treatment should have been on the care plan, but they were not documented there.
Air Mattress Set Incorrectly for Resident With Stage IV Sacral Ulcer: A resident with quadriplegia, trach and PEG status, and an unhealed stage IV sacral ulcer was observed on a low air loss mattress pump set to 380 lbs despite a documented weight of 149 lbs. The DON stated the setting should match the resident’s weight, while an LPN said she was not sure the dial should correlate to weight and had not been trained on it. Nursing staff reported checking the mattress each shift by observation, but the pump remained set at 380 lbs during repeated observations.
Failure to follow ordered oxygen therapy: A resident with encephalopathy, subarachnoid hemorrhage, heart failure, hypoxic hypercapnic respiratory failure, and OSA was observed receiving O2 via NC at 3 L/min even though the EMR and care plan ordered 4 L continuously. The resident was seen in bed and in the dining room with the oxygen concentrator set below the ordered rate, and the LPN, Unit Manager, and DON all confirmed the discrepancy and that nurses were expected to verify the setting each shift.
An LPN administered Eliquis to a resident without verifying that the label matched the resident, and later confirmed the medication had been taken from another resident’s labeled supply. The resident had A-fib and intact cognition, and the facility’s records showed the resident had an active Eliquis order. Staff interviews described confusion from moving medications between carts, and the DON confirmed the facility policy required checking the label three times before administration.
The facility failed to timely address consultant pharmacist recommendations for two residents. One resident with dementia and ESRD had unresolved pharmacy concerns involving bisacodyl, MOM, and lisinopril BP documentation, while another resident had diltiazem administered without required BP hold-parameter documentation on the MAR. The DON and UM confirmed the recommendations were not completed within the facility’s expected timeframe and were not documented as addressed.
A resident with cognitive intactness and diagnoses including depressive episodes received Abilify and Lexapro for depression, but the EMR contained no documentation that the resident or RP consented to the psychotropic meds. The psych NP stated she could not reach the RP to review risks, benefits, and side effects, and a follow-up note lacked documentation of justification, diagnosis, or target symptoms; the DON stated the facility did not use signed consent and could not provide consent documentation.
The facility did not ensure that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors identified deficiencies in food storage and kitchen sanitation, including mold on refrigerator gaskets, debris near food storage, and moldy bagels. Dented cans were improperly stored, and kitchen equipment had significant cleanliness issues. The FSD acknowledged these problems, which were contrary to facility policies on sanitation and food storage.
The facility failed to accurately complete MDS assessments for three residents, leading to documentation deficiencies. One resident's tobacco use was not recorded, another's dialysis treatment was omitted, and a third's behavioral disturbances were not documented. The MDS Coordinator acknowledged these oversights during interviews.
A facility failed to ensure proper respiratory care and equipment maintenance for a resident with COPD. The resident's nebulizer machine was observed with unlabeled tubing, an uncovered mask, and visible debris, indicating a lack of cleaning. Staff interviews revealed inconsistencies in equipment maintenance procedures, and the facility's policy was not consistently followed, leading to the deficiency.
A resident did not receive their preferred meal during lunch service, as the facility ran out of pork chops and served fish instead, despite the resident's known dislike for fish. The meal served did not match the meal ticket, and the Food Service Director acknowledged the oversight. Facility policies on meal accuracy and resident preferences were not followed.
A resident with dysphagia was not provided with the correct liquid consistency as per physician orders. The LPN used an incorrect amount of thickener, resulting in a liquid that was not honey thick. The SLP and RD confirmed the inconsistency, and the DON acknowledged the failure to follow orders. Prethickened liquids were available but not utilized.
Unsafe Food Storage and Preparation Practices
Penalty
Summary
The facility failed to store and prepare food in a manner consistent with kitchen sanitation practices in both the main kitchen and the ethnic specialty kitchen. During the initial tour of the main kitchen, a cloth bag containing a staff member’s food was found stored in a refrigerator used for resident items, and the Food Service Director acknowledged it should not have been there. The walk-in freezer had visible ice buildup on the floor mat, shelves, refrigeration unit, ceiling, and food packaging boxes, and opened boxes contained inner plastic bags that were not closed with frost and loose ice on the food items. In the walk-in cooler, boxes of shelled raw eggs were stored on a shelf above the bottom shelf, and the Food Service Director acknowledged they should have been on the bottom shelf. In the dishwashing area, the chemical sanitizer bucket for the low-temperature dish machine was empty while dishes were being processed, and the Regional FSD stated items washed that morning needed to be run through again because they were not sanitized. On the pot drying shelves, several deep quarter pans were stacked on their sides, and when separated, brown powdery residue was found on the pans; the Food Service Director acknowledged they were not clean. Later, a Dietary Aide washed a green apple at the handwashing sink, dried it, wrapped it in plastic, and placed it with other fruit for service. The surveyor also observed a box of tilapia in the freezer with open clear plastic packaging, exposed fish, and frost and loose ice on the fish, and the Food Service Director acknowledged the packaging should have been closed. In the ethnic specialty kitchen, the food preparation room door was propped open and a tower fan with visibly dirty intake vents was running toward the food preparation area while staff prepared food. On a later observation, a Dietary Aide was seen kneeling on the floor and striking a bag with a hammer to break up solid unrefined sugar. The sugar had been placed into a large bag labeled for whole wheat flour, and the aide acknowledged the bag was not labeled as sugar and that she used the flour bag because it was empty. Facility policies reviewed by the surveyor addressed safe food handling, food storage, and refrigerator and freezer sanitation.
Infection Control Failures in Kitchen, Tracheostomy Care, and Dining Service
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program in multiple areas, including kitchen hand hygiene, tracheostomy care, and hand hygiene during meal service. In the main kitchen, a staff member was observed wiping bare hands on pant legs, then putting on gloves to transport a bin of seasoned raw chicken to the refrigerator without hand hygiene being performed. In the ethnic specialty kitchen, a dietary aide handled dough-like food items with bare hands, shaping and dredging them repeatedly without gloves. In the main kitchen, another staff member was observed performing handwashing incorrectly, including rubbing soap over hands and forearms, rinsing briefly, drying with paper towels, and then using the towels on her face and hand before donning gloves and returning to work. A later observation showed a dietary aide using the rinse sink of a three-bay sink to wash hands, then leaving the kitchen without proper hand hygiene. The Infection Preventionist stated she was responsible for hand-washing competency testing for kitchen staff, but competency forms were not provided for two staff members. The facility also failed to maintain appropriate infection control practices during tracheostomy care for a resident with acute and chronic respiratory failure, tracheostomy status, gastrostomy status, a stage 4 sacral pressure ulcer, and quadriplegia. Two RNs performed tracheostomy care while the resident had a BIMS score of 0 and was rarely understood. During the procedure, one RN removed soiled tracheostomy gauze, then donned sterile gloves without performing hand hygiene first. When the second RN returned with supplies, she donned nonsterile gloves without hand hygiene and opened the inner cannula package. The RNs initially performed the procedure without gowns or masks, and one RN stated they were not wearing any PPE besides gloves and should have worn a mask and gown. The resident’s care plan and physician orders included enhanced barrier precautions, tracheostomy care every shift and as needed, and daily inner cannula changes. In the dining room, a CNA delivered lunch trays, then began feeding one resident while touching another resident on the shoulder without performing hand hygiene. The CNA later left the dining room to retrieve a folding chair and returned to continue feeding the first resident without performing hand hygiene. During interviews, the CNA acknowledged that touching other residents while feeding could spread germs and that hand hygiene should have been performed before feeding. The LPN/UM and DON both stated that hand hygiene was expected before and after feeding residents and after tray delivery, and that staff should not touch other residents while feeding.
Resident Fed While Staff Stood and Sat Behind Them
Penalty
Summary
The facility failed to maintain the dignity of an unsampled resident who required assistance with eating during lunch on Cedar Unit. During observation, a CNA was seen feeding the resident while standing up. When the LPN/UM instructed the CNA to sit down, the CNA left the dining room, returned with a folding chair, and then sat behind and to the right of the resident while continuing to feed them. The CNA later stated that staff were supposed to be sitting on the side of or next to the resident when assisting with feeding and should be facing the resident to observe chewing and the resident’s face, and acknowledged that standing while feeding was a mistake. The LPN/UM stated staff should always be sitting and not standing when feeding residents for dignity. The DON also stated staff should sit while feeding residents, that they should have direct eye contact to ensure the resident is swallowing before giving more food, and that sitting behind the resident would prevent seeing the resident. Facility policy on resident rights stated residents have the right to receive services with reasonable accommodations to individual needs and preferences, and the assisting-meals policy stated that if seated during feeding, a chair should be positioned where it is convenient for both staff and resident.
Call Bell Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that Resident #184’s call bell was readily accessible and within reach. On 4/9/26, the resident was observed resting in bed with the call bell on the floor to the left of the nightstand, out of reach. When asked how staff would be summoned for help, the resident stated they would shout out for help. On 4/10/26, the resident was again observed sitting in a wheelchair with the call bell still on the floor in the same location, and the resident stated they did not know where the call bell was and would call out for help or come out of the room to ask for help. Resident #184’s record showed diagnoses including hypertension, cerebral infarction, hemiplegia, and hemiparesis following cerebral infarction affecting the right dominant side. The quarterly MDS dated 1/16/26 indicated a BIMS score of 9 out of 15, showing moderately impaired cognition, and also noted impairment on one side in the upper and lower extremities with maximal assistance needed for ADLs. The care plan included interventions to keep the call light in reach, keep the call bell within reach, and encourage the resident to use the call bell to call for assistance. During interviews, the CNA assigned to the resident stated she would make sure the call bell was in reach before leaving the room and that it was important to keep it within reach for safety. The LPN stated she would ensure the resident had the call bell with them before leaving the room and that staff should place it within reach when assisting the resident back to bed. The LPN/UM and DON both stated the call bell should be in reach at all times because it was how the resident would call for help, and the facility’s policy required call bells to be within reach before leaving the room.
Untimely Background and Reference Checks for Newly Hired Employees
Penalty
Summary
The facility failed to implement its abuse policy by not completing timely background checks for 4 of 155 newly hired employees and not completing timely reference checks for 3 of 155 newly hired employees. The employees identified with untimely background checks were a Speech Therapist with a date of hire of 7/7/25, an RN with a date of hire of 7/18/25, an RN with a date of hire of 3/27/26, and an Occupational Therapist with a date of hire of 6/23/25. The background checks for these employees were completed either before the date of hire by a wide margin, after the date of hire, or were dated years earlier than the hire date. The employees identified with reference check issues included a CNA with a date of hire of 8/20/25 for whom there was no evidence of reference checks prior to employment, an RN with a date of hire of 3/17/25 whose reference checks were completed before hire but dated 7/3/24, and a Housekeeper with a date of hire of 3/9/26 whose two reference check forms were not signed or dated by the facility. The facility’s policy stated that screening components include verification of references and criminal background checks prior to working with residents, and that employment is contingent upon acceptable background check results. The LNHA, DON, and other leadership were informed of the concerns, and the facility could not provide additional information for the identified employee file deficiencies.
Failure to Include Asthma and Nebulizer Treatment in Care Plan
Penalty
Summary
The facility failed to develop an individual comprehensive care plan (ICCP) for a resident with Asthma and nebulizer treatments. Resident #69 was admitted with diagnoses including cerebral infarction, Asthma, and hypertension, and the most comprehensive MDS dated 2/20/2026 showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact. On 04/09/2026, the surveyor observed the resident’s nebulizer tubing and mouthpiece on the table in a clear plastic bag dated 4/8/2026. The physician order summary as of 4/10/2026 included scheduled Ipratropium-Albuterol inhalation solution via nebulizer three times daily for shortness of breath/wheezing and an additional order every 6 hours as needed for wheezing. Review of the ICCP showed a focus for ADL self-care performance deficit related to fatigue, initiated on 12/8/2025, but no focus for Asthma or nebulizer treatment. During interviews, the LPN stated that a care plan should include a resident’s asthma diagnosis and nebulizer treatment because it was a breathing concern, and confirmed there was no record of those items in the care plan. The UM stated that a resident with asthma should definitely be included on the care plan and confirmed there was no respiratory care or asthma diagnosis on the resident’s care plan. The DON stated that the care plan depicts the care and services the resident receives and confirmed that the diagnosis and treatment should have been on the resident’s care plan.
Air Mattress Set Incorrectly for Resident With Stage IV Sacral Ulcer
Penalty
Summary
The facility failed to ensure that a low air loss pressure-reducing mattress was functioning properly and set according to the resident’s weight for a resident with an altered skin integrity history. Resident #16 was observed lying in bed on an air mattress with the pump set to 380 pounds, while the resident’s documented weight was 149 pounds. The resident had diagnoses including acute and chronic respiratory failure, tracheostomy status, gastrostomy status, quadriplegia, and an unhealed stage 4 sacral pressure ulcer present on admission. The resident’s MDS reflected severe cognitive impairment and that the resident was rarely understood. The care plan included interventions for the sacral wound, limited mobility, two-staff assistance for care and repositioning, and skin care to prevent breakdown. Physician orders included repositioning every hour and use of two wedges to offload the sacrum every 2 hours, including overnight, for the stage IV sacral ulcer. Wound care notes showed the wound was being followed weekly and remained stable/unchanged on the most recent documented evaluation. During observations, the mattress pump continued to be set at 380 pounds on multiple occasions while the resident was in bed. The DON stated that if an air mattress pump had weight settings on the dial, it should be set to the resident’s weight to ensure proper pressure distribution. The LPN caring for the resident stated that nursing staff checked the mattress each shift by observing whether the resident looked okay in bed, but also stated she was not really sure whether the number on the dial should correlate to the resident’s weight and that she had not been trained on it. The LNHA and DON later acknowledged that an air mattress should be set according to a resident’s weight to prevent skin breakdown and promote healing.
Failure to Follow Ordered Oxygen Therapy
Penalty
Summary
The facility failed to follow a physician’s order for oxygen therapy for Resident #101. The resident was admitted with diagnoses including encephalopathy, other nontraumatic subarachnoid hemorrhage, and heart failure, and the most recent MDS showed a BIMS score of 8 out of 15. The care plan identified altered respiratory status related to hypoxic hypercapnic respiratory failure and OSA, with oxygen settings documented at 4 L via nasal cannula continuously. The physician’s order in the EMR also directed oxygen at 4 L continuously via nasal cannula every shift. During multiple observations, the surveyor saw the resident receiving oxygen via nasal cannula at 3 L per minute while in bed, in the dining room eating lunch, and later while eating breakfast. The resident stated they always wore the nasal cannula and received oxygen continuously. The surveyor and LPN confirmed that the oxygen concentrator in the room was set at 3 L, and the LPN acknowledged the order was for 4 L continuously. The Unit Manager and DON also verified the physician’s order for 4 L and stated that nurses were supposed to check the oxygen concentrator settings each shift. The facility’s Oxygen Administration policy required verification of a provider order and review of the physician’s orders before oxygen administration.
Medication Label Verification Failure During Eliquis Administration
Penalty
Summary
The facility failed to ensure professional standards of nursing practice were followed when an LPN administered Eliquis to a resident without first verifying that the medication label matched that resident. During a medication pass, the LPN gave nine medications, including Eliquis 5 mg, to the resident in the room. After returning to the cart, the LPN and surveyor reviewed the package label and found that the Eliquis had been removed from a package labeled for another resident. The LPN stated she did not realize the resident's name was wrong and acknowledged she should have read the name on the label before administering the medication. The resident involved had diagnoses including atrial fibrillation and had a BIMS score of 14 out of 15, indicating intact cognition. The resident also spoke another language and required an interpreter. The EMAR and order summary showed an active order for Eliquis 5 mg twice daily for atrial fibrillation. The surveyor also reviewed the medication record for the other resident whose label was on the package and found that resident had an active Eliquis order as well, but for administration via G-tube. Interviews with facility staff showed that the other resident had been discharged to the hospital and later returned to the unit, and that medications were sometimes moved between carts based on nursing assignments. The unit clerk and LPN described confusion related to cart assignments and medication storage, and the DON stated nurses would sometimes switch residents or move medications between carts for convenience. The facility policy required the medication label to be checked three times to verify the right medication, dosage, time, and method before administration, and the DON confirmed the LPN was inserviced on the five rights of medication administration.
Delayed Response to Consultant Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to respond timely to monthly Consultant Pharmacist recommendations for 2 of 5 residents reviewed for unnecessary medications. For one resident with unspecified dementia, end stage renal disease, and dependence on renal dialysis, the consultant pharmacist issued recommendations in February and March 2026 to clarify a bisacodyl order that referenced Milk of Magnesia when no MOM order was on the MAR, and to clarify a lisinopril order so blood pressure could be documented with each dose. The MARs showed lisinopril was administered on the ordered Monday/Wednesday/Friday schedule without the required blood pressure documentation, and bisacodyl remained ordered as PRN for constipation/MOM ineffective despite no MOM order being present. The unit manager acknowledged the February and March recommendations were the same, that they were not addressed in the medical record, and that he should have documented that the issues were clarified. The DON stated the consultant pharmacist reports were printed and given to unit managers, that every recommendation should be addressed even if the physician refused, and that the recommendations should be completed within a week. The DON also acknowledged the resident’s pharmacy recommendations were late and not addressed within the required timeframe. For another resident who was cognitively intact and receiving antidepressant, anticoagulant, antibiotic, hypoglycemic, antiplatelet, and antipsychotic medications, the consultant pharmacist identified a high-priority recommendation to clarify diltiazem orders so hold parameters and blood pressure documentation could be added to the MAR. The MAR showed diltiazem was administered three times daily without the required blood pressure documentation until 12 days after the recommendation. The UM and DON both confirmed the supplemental documentation was not added when recommended and that the recommendation was not addressed within the facility’s stated 7-day timeframe.
Failure to Document Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent to ensure that Resident #46 did not receive an unnecessary medication, involving psychotropic medications ordered for depression. Resident #46 was admitted with diagnoses including other specified mental disorders due to a known physiological condition and other specified depressive episodes, and the admission MDS dated 3/20/26 showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact. The resident’s EMR showed orders for Aripiprazole 5 mg daily for major depressive disorder and Escitalopram 10 mg daily for depression, both started on 3/17/26, and the March 2026 MAR documented these medications as administered as ordered. Review of the progress notes showed no documentation that the resident or resident representative consented to the psychotropic medications. During interviews, the UM stated the psychiatric NP typically spoke with the family about the resident’s history and behaviors before changes were made, while the psychiatric APN stated she was unable to reach the resident’s representative to discuss the risks, benefits, and common and adverse side effects of the medications. The APN also stated that a colleague’s follow-up note showed the resident’s representative was present, but there was no documentation of additional information regarding risks, benefits, side effects, justification, diagnosis, or target symptoms for Lexapro and Abilify. The DON stated the facility did not use signed consent and that if it was not documented, it was not done, and the DON was unable to provide consent for the psychotropic medication administration.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by anybody. This deficiency indicates that residents were not adequately safeguarded from potential or actual harm caused by others, as required by regulations. The report identifies a lapse in the facility's responsibility to ensure a safe environment free from abuse and neglect for all residents. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions, are provided in the report.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to store potentially hazardous foods properly and maintain kitchen equipment in a sanitary manner, leading to potential foodborne illness risks. During a kitchen tour, surveyors observed several deficiencies, including mold on refrigerator gaskets, debris on a windowsill near food storage, and moldy bagels on a bread rack. The Food Service Director (FSD) acknowledged these issues, noting that the Assistant FSD, responsible for rotating bread, was not present. Additionally, dented cans were found in the dry storage area, which the FSD admitted should not have been there. Further observations revealed significant cleanliness issues with kitchen equipment. The double stack convection ovens and metal shelves over the range had a heavy buildup of black debris, which the FSD recognized as needing cleaning. A slicer, not in use, had a soiled oven mitt on it and light brown debris on the blade and base. The facility's policies on sanitation and food storage were reviewed, indicating that the food service area should be maintained in a clean and sanitary manner, with food rotated using a first-in, first-out method.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of their care needs. For one resident with Alzheimer's disease, the MDS was incorrectly coded to indicate no current tobacco use, despite observations of the resident smoking with staff supervision. The MDS Coordinator acknowledged the oversight during an interview with the surveyor. Another resident, who had end-stage renal disease and was dependent on dialysis, had an MDS that did not reflect their dialysis treatment, despite the resident's care plan indicating a dialysis schedule and potential complications. The MDS Coordinator admitted to not seeing a note regarding the dialysis at the time of the assessment. A third resident, diagnosed with moderate dementia and exhibiting behavioral disturbances, had an MDS that failed to document these behaviors, despite electronic medical records indicating episodes of cursing, kicking, and throwing objects. The MDS Coordinator confirmed that the behaviors were not coded in the MDS and acknowledged the need for accuracy in assessments. The facility's policy on the Resident Assessment Instrument MDS emphasizes the importance of using the mandated MDS form to conduct resident assessments and correcting any errors when discovered.
Inadequate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide necessary respiratory care and services in a manner that prevents the spread of infection for a resident with chronic obstructive pulmonary disease (COPD) and other medical conditions. The surveyor observed the resident's nebulizer machine on the dresser, surrounded by personal items, with unlabeled and undated tubing. The nebulizer mask was uncovered and exposed to the air, and the exterior of the machine had yellowish stains and brown fuzzy debris. These observations were made on multiple occasions, indicating a lack of proper cleaning and maintenance of the equipment. Interviews with the resident and staff revealed inconsistencies in the facility's process for maintaining nebulizer equipment. The resident reported that the tubing was changed weekly, but had never seen the staff clean the nebulizer machine. The Unit Manager LPN and the Infection Preventionist confirmed that the tubing and masks were changed weekly, and the masks should be cleaned and stored in a bag after each use. However, there was no established procedure for cleaning the exterior of the nebulizer machine. The facility's policy required respiratory equipment to be changed weekly and stored in a plastic bag between uses, but this was not consistently followed, leading to the deficiency.
Failure to Provide Accurate and Preferred Meal Items
Penalty
Summary
The facility failed to ensure that a resident received their preferred and accurate meal items during lunch service, as indicated on the meal ticket. This deficiency was observed when a resident, who had ordered pork chops, was served fish instead, despite having previously informed the staff of their dislike for fish. The resident's meal ticket specified herb breaded pork chops, rice pilaf, braised cabbage, fruited yogurt, whole milk, juice, and coffee, but the tray contained fish fillet with lemon dill sauce, rice pilaf, oriental zucchini, skim milk, and juice. The Licensed Practical Nurse and Unit Manager acknowledged the discrepancy between the meal served and the meal ticket. The Food Service Director admitted that the kitchen ran out of pork chops due to high demand and failed to notify the resident of the substitution. Additionally, the Registered Dietitian noted that not receiving preferred meals could place residents at nutritional risk. The facility's policies on resident food preferences and meal distribution emphasize the importance of documenting resident likes and dislikes and ensuring meal accuracy, which were not adhered to in this instance.
Failure to Provide Correct Liquid Consistency for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident received liquids in the appropriate consistency at bedside in accordance with physician orders. This deficiency was identified for a resident who had a diagnosis of dysphagia and was on a mechanically altered diet requiring honey thick liquids. Despite having a physician's order for a honey consistency diet, the resident was observed with a 16-ounce water cup that was not within reach, and the liquid was not prepared to the required consistency. The Licensed Practical Nurse (LPN) responsible for preparing the resident's water used an incorrect amount of thickener, resulting in a liquid that was not honey thick. The LPN mixed 16 ounces of water with three thickener packets, whereas the instructions required two packets for every four ounces to achieve the correct consistency. The Speech Language Pathologist (SLP) and Registered Dietitian (RD) confirmed that the liquid was not thick enough, and the SLP noted that the powder used often resulted in separation, with the liquid not maintaining the required consistency. The facility had prethickened liquids available in the kitchen, but the LPN did not contact the kitchen to obtain them. The Director of Nursing (DON) acknowledged that the nurse did not follow the physician's order and that the liquid was not of the correct consistency. The facility's policy required that no water pitcher or other thinned liquids be at the bedside of residents ordered thickened liquids, which was not adhered to in this case.
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 795 citations issued within 25 miles in the last 12 months — including the 18 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 South Plainfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Embassy Manor At Edison Nursing And Rehabilitation | 1.4 mi | ★★★★★ | 0 | 0 |
| Hartwyck At Oak Tree | 2.8 mi | ★★★★★ | 0 | 0 |
| Accelerate Skilled Nursing And Rehab Piscataway | 3.5 mi | ★★★★★ | 3 | 1 |
| Brighton Gardens Of Edison | 3.6 mi | ★★★★★ | 1 | 0 |
| Careone At The Highlands | 3.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Aristacare At Cedar Oaks.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.