Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Complete Care At Cedar Grove during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
Surveyors found a black, fungi-like substance behind wallpaper and dressers in two resident rooms, confirmed by maintenance staff, the Administrator, and the Regional Director of Operations. Maintenance staff had previously reported the issue to Administrators, but no action was taken. Facility policy and job descriptions require maintaining a clean, safe, and homelike environment, which was not upheld.
The facility failed to adhere to infection control measures and physician's orders for oxygen therapy. A resident's nasal cannula tubing was improperly stored, and two residents received oxygen at incorrect flow rates. The facility did not follow its policy for changing and storing tubing, and staff neglected to adjust oxygen settings as per orders.
The facility failed to ensure call bells were within reach for three residents, each with significant impairments. One resident with hemiplegia and cognitive impairment had the call bell dangling out of reach. Another resident with cerebrovascular disease had the call bell placed on the wrong side, contrary to their care plan. A third resident with visual impairment found their call bell on the floor. Staff acknowledged these oversights, and the DON confirmed the expectation for call bells to be accessible.
A facility failed to follow physician orders for a resident's medication, Entresto, which was to be held if the systolic blood pressure (SBP) was below 110. Despite the resident's SBP being below this threshold on several occasions, the medication was administered. The LPN acknowledged the error, and the DON confirmed the absence of a specific policy on following physician orders.
The facility failed to provide pharmaceutical services in accordance with professional standards, including improper storage of intravenous bags, inaccurate dispensing and administration of pain medication, and unavailability of a narcotic medication as ordered by a physician. Intravenous bags were found without tamper-resistant packaging, and discrepancies were noted in the administration of Oxycodone and Clonazepam due to deviations from physician orders and lack of proper documentation.
An LPN in a facility failed to administer medications according to prescribed instructions, resulting in a medication error rate of 7.41%. The LPN attempted to give Metformin and Potassium Chloride to a resident without ensuring they had eaten, despite instructions to take the medications with food. The error was identified during a surveyor's observation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Failure to Maintain Clean and Homelike Resident Rooms Due to Black Fungi-Like Substance
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and homelike environment in two of four resident bedrooms, as evidenced by the presence of a black dried substance, described as fungi-like, behind the wallpaper and dressers. The Director of Maintenance and maintenance staff confirmed the presence of this substance during the inspection and acknowledged that the affected sheet rock should have been replaced. The maintenance staff reported that he had previously informed both the prior and current Administrators about the issue, but no corrective action had been taken. Additionally, a registered nurse stated she had noticed the black substance and reported it to the Administrator and maintenance, but could not recall the method of reporting. The Administrator, upon being shown the affected rooms, confirmed the presence of the black dried substance and stated that he was previously unaware of the issue. The Regional Director of Operations also confirmed the findings during the tour. Review of job descriptions indicated that maintenance staff are responsible for moving furniture to complete assignments and that the Director of Maintenance is responsible for ensuring compliance with regulations. The facility's policy requires providing a safe, clean, and homelike environment, which was not met in this instance.
Deficiencies in Oxygen Therapy and Infection Control
Penalty
Summary
The facility failed to ensure proper infection control measures and adherence to physician's orders for oxygen therapy for several residents. Resident #55 was observed with a nasal cannula tubing dated 9/26/24, improperly stored and touching the floor, which was not in accordance with infection control measures. The facility policy required the tubing to be changed weekly and stored in a plastic bag, which was not followed. The resident's care plan indicated the use of oxygen therapy as needed for ineffective gas exchange, but the tubing was not managed properly. Resident #28 was found with undated nasal cannula tubing not stored in a plastic bag, contrary to the facility's infection control policy. The resident had a moderate cognitive impairment and required oxygen therapy as needed for shortness of breath. The facility's failure to date and store the tubing correctly indicated a lapse in following infection control protocols. Residents #160 and #273 were both receiving oxygen therapy at incorrect flow rates, not in accordance with physician's orders. Resident #160's oxygen concentrator was set at 3.5 LPM instead of the ordered 2 LPM for congestive heart failure. Similarly, Resident #273's oxygen concentrator was set at 3 LPM, while the order was for 2 LPM. The facility staff failed to adjust the oxygen settings as per the physician's orders, and the eMAR for Resident #273 was not consistently signed to confirm administration. These discrepancies highlight a failure in ensuring that physician's orders were followed accurately.
Failure to Ensure Call Bells Within Reach of Residents
Penalty
Summary
The facility failed to maintain the call bell within reach of residents, affecting three residents. Resident #108 was observed with the call bell dangling towards the floor, not within reach, despite having hemiplegia, hemiparesis, and severe cognitive impairment. The resident's care plan indicated impaired vision and required consistent placement of items. Similarly, Resident #128, who had cerebrovascular disease and severe cognitive impairment, was found with the call bell out of reach on the right side, contrary to the care plan's instruction to keep it on the left side where the resident's arm was stronger. The CNA acknowledged the oversight, noting the resident's inability to speak and reliance on the call bell for assistance. Resident #116, with severe visual impairment and intact cognition, was found with the call bell on the floor, out of reach. The resident expressed reliance on the call bell for assistance, and the LPN confirmed the call bell should always be within reach. The CNA responsible for Resident #116 admitted to not ensuring the call bell was accessible. The Director of Nursing confirmed the expectation for call bells to be within residents' reach, highlighting a consistent failure to accommodate residents' needs and preferences as required.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to maintain professional standards of nursing practice by not adhering to physician orders for medication administration for a resident. The resident had a physician's order for Entresto, a medication used to treat high blood pressure, with specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 110. However, the Electronic Medication Administration Records for November 2024 showed that the medication was administered on several occasions when the resident's SBP was below 110. The Licensed Practical Nurse (LPN) acknowledged that the medication should have been withheld on the specified dates when the resident's SBP was lower than 110. Despite the administration of the medication, the LPN noted that there were no negative outcomes for the resident. Additionally, the Director of Nursing (DON) confirmed that the facility did not have a specific policy regarding adherence to physician orders, which contributed to the deficiency.
Deficiencies in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, as evidenced by several deficiencies identified during a survey. Firstly, intravenous bags were found to be stored without tamper and contaminant-resistant packaging. Specifically, a bag of sodium chloride for injection and a bag of dextrose for injection were observed without outer packaging or seals, which was confirmed by the Assistant Director of Nursing/Infection Preventionist as a deviation from standard practice. Additionally, there was an issue with the accurate dispensing and administration of pain medication. A discrepancy was noted in the count of Oxycodone Immediate Release tablets for a resident, where the physical count did not match the inventory log. The discrepancy arose because an LPN administered the medication earlier than the scheduled time without informing the physician, which also prevented proper documentation in the electronic Medication Administration Record (eMAR). Furthermore, the facility failed to ensure that a narcotic medication ordered by a physician was available for administration. A resident's declining inventory log for Clonazepam showed that the medication was administered in a manner inconsistent with the physician's order due to the unavailability of the correct dosage. An LPN administered double the dose of a lower strength medication without obtaining a physician's order, which was confirmed by the LPN/Unit Manager as inappropriate and could lead to a shortage of medication before the next refill.
Medication Administration Error Due to Failure to Follow Food Instructions
Penalty
Summary
The facility failed to ensure that medications were administered without error, resulting in a medication error rate of 7.41%, which exceeds the acceptable threshold of 5%. During a medication observation, a surveyor noted that an LPN prepared and attempted to administer medications to a resident without ensuring the resident had eaten, despite the medications requiring administration with food. The medications involved were Metformin and Potassium Chloride, both of which had specific instructions to be taken with food to prevent potential adverse effects such as stomach irritation and low blood sugar. The incident occurred when the LPN prepared the medications and was ready to administer them, even though the resident had not received their breakfast. The surveyor intervened and reviewed the resident's electronic Medication Administration Record (eMAR) and the bingo card with the LPN, confirming the instructions to take the medications with food. The LPN acknowledged the error and the potential consequences of administering the medications on an empty stomach. The facility's policy on administering medication emphasizes the importance of following prescribed orders, including any specific instructions regarding timing and food requirements.
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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 Cedar Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alaris Health At Cedar Grove | 0.7 mi | ★★★★★ | 28 | 0 |
| Canterbury At Cedar Grove | 0.8 mi | ★★★★★ | 13 | 0 |
| Complete Care At St Vincents Llc | 1.3 mi | ★★★★★ | 0 | 0 |
| Arbor Glen Center | 1.8 mi | ★★★★★ | 29 | 0 |
| Family Of Caring Healthcare At Montclair | 2.3 mi | ★★★★★ | 0 | 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.