Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Cedarvale Commons Rehabilitation And Healthcare Ce during CMS and state inspections, most recent first.
The facility did not consistently serve meals according to planned menus, resulting in incorrect portion sizes, unavailable always-available menu items, and meal trays that did not match residents' dietary orders. Two residents did not receive grilled cheese sandwiches as listed on the always-available menu, and two others did not receive the correct items as specified on their meal tickets. Staff confirmed these issues, and residents reported frequent mismatches between what was served and what was ordered.
Several infection control deficiencies occurred, including failure to post required isolation signage for residents on enhanced barrier or contact precautions, improper disinfection and reuse of a glucometer between residents by an LPN, and inadequate hand hygiene during tube feeding and wound care. Staff were observed not following facility policies, and family members were not educated or provided PPE when entering a room of a resident with an active C. diff infection.
Two residents experienced deficiencies in their living environment, with one resident's air conditioning unit found to be dirty and emitting a foul odor, and another resident's bathroom exhibiting a persistent leak with water seeping through the floor. Both issues were confirmed by the Maintenance Director and were not addressed in accordance with facility policy.
A resident with multiple health conditions and cognitive impairment experienced significant, unaddressed weight loss due to the facility's failure to complete nutritional assessments, follow orders for weekly weights and meal assistance, and provide proper documentation. Staff did not consistently assist the resident with meals or offer alternatives when food was refused, and there was confusion about implementing physician orders. Record-keeping issues after a change in ownership further contributed to the lack of oversight and monitoring.
A resident with multiple medical conditions was incorrectly placed on a mechanically soft diet due to a documentation error and lack of current assessment, despite no evidence of swallowing or chewing issues. The resident consumed less than half of provided meals and expressed dissatisfaction with the diet, relying on family for food until the error was identified and corrected.
The facility did not complete reference checks for newly hired CNAs and LPNs, and lacked a written policy requiring such checks or screening for histories of abuse, neglect, or exploitation. This deficiency was confirmed by both the DON and Administrator, and affected all residents in the facility.
The facility failed to provide appropriately sized incontinence briefs for three bariatric residents, leading to discomfort and inadequate care. A resident with chronic respiratory failure and incontinence, along with two other residents with similar needs, were frequently found without the necessary 3XL incontinence briefs. Staff interviews and observations confirmed the absence of these briefs, forcing the use of ill-fitting alternatives. The deficiency was identified during a complaint investigation.
A facility failed to change oxygen tubing monthly for a resident due to a lack of supplies. The resident, with conditions like acute respiratory failure and congestive heart failure, required continuous oxygen therapy. Staff interviews and observations confirmed the absence of oxygen cannulas in storage, and the resident's tubing was not replaced as per policy.
Failure to Follow Menus and Provide Planned Meals
Penalty
Summary
The facility failed to ensure that menus were followed and that residents received meals as planned, resulting in multiple deficiencies related to meal preparation and service. Observations revealed that dietary staff did not consistently use the correct portion sizes when serving food, such as not fully filling four-ounce scoops for broccoli and using three-ounce scoops instead of the required four-ounce scoops for pork. Staff interviews confirmed these inconsistencies, and the Dietary Director acknowledged that the wrong scoop sizes were used and that it was the cook's responsibility to ensure proper portions. Additionally, the facility did not provide items listed on the always available menu to residents who requested them. On one occasion, a resident requested a grilled cheese sandwich, which was listed as always available, but was not provided because the kitchen had run out of cheese. The Dietary Director confirmed that the item should have been available but was not due to a lack of ingredients. Another resident's meal ticket specifically requested a grilled cheese, but the item was not provided, and the resident reported that this mismatch between the meal ticket and what was served happened frequently. Further review of meal tickets and resident records showed that residents with specific dietary needs and orders did not receive the correct menu items. For example, one resident on a carb-controlled, pureed diet was served mashed potatoes instead of pureed sweet potatoes as ordered, and another resident on a no added salt, mechanical soft diet did not receive green beans as indicated on the meal ticket. Staff interviews and documentation confirmed that these discrepancies occurred, and residents reported dissatisfaction with the food and frequent mismatches between the menu and what was served.
Multiple Infection Control Failures in Resident Care and Isolation Practices
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices for multiple residents, resulting in several deficiencies. For residents with indwelling urinary catheters and wounds, such as those with orders for enhanced barrier precautions (EBP), the required signage indicating isolation status was not posted in or outside their rooms. In one instance, a resident with a confirmed Clostridioides difficile (C. diff) infection did not have contact precaution signage posted, and family members were observed entering the room without personal protective equipment (PPE) or education on infection risks. Staff interviews confirmed that appropriate isolation precautions were not implemented despite physician orders and facility policy requirements. During medication administration, an LPN failed to properly disinfect a glucometer between uses for different residents. The same disinfectant wipe was used to clean the glucometer after one resident's blood glucose check and then reused for another resident, contrary to manufacturer instructions and facility policy, which specify single-use and proper dwell time for disinfection. The LPN also acknowledged not following the required drying time for the disinfectant to be effective. This practice was observed and confirmed through staff interviews. In another incident, a CNA providing incontinence care to a resident with a stage four pressure ulcer inadvertently wiped feces into the wound bed before wound care was performed. The LPN performing the wound care acknowledged that feces in the wound bed was problematic and had occurred previously, requiring additional cleansing. Additionally, during tube feeding administration for a resident with a gastrostomy tube, an LPN touched the floor with gloved hands and did not change gloves or perform hand hygiene before continuing the procedure. These actions were observed and confirmed by staff, and were not in accordance with facility infection control policies.
Failure to Maintain Cleanliness and Plumbing in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents as evidenced by two separate incidents involving environmental deficiencies. In the first incident, a resident with multiple diagnoses including epilepsy, anxiety, dementia, diabetes, psychotic disorder, and heart failure was found to have a personalized air conditioner (PTAC) in their room that was visibly dirty, with a thick layer of dust and large pieces of debris on the vent. When the resident turned on the PTAC, a foul, trash-like smell was emitted. Multiple observations confirmed that the PTAC unit had not been cleaned, and the Maintenance Director acknowledged responsibility for its upkeep. Facility policy required cleaning schedules to be developed and implemented to maintain all areas, but this was not followed in this case. In the second incident, another resident with pulmonary disease, heart disease, and visual loss reported a leak in their bathroom. Observation revealed that water beads would seep through the cracks between the floorboards when pressure was applied, indicating a plumbing issue. The Maintenance Director confirmed the presence of water beads coming up from the bathroom flooring. Again, facility policy required maintenance of all areas, but the plumbing issue was not addressed, resulting in an unclean and potentially unsafe environment for the resident.
Failure to Provide Adequate Nutritional Support and Monitoring
Penalty
Summary
The facility failed to ensure that a resident identified as being at risk for nutritional problems and malnutrition maintained acceptable parameters of nutritional status. The resident, who had multiple diagnoses including respiratory failure, dysphagia, diabetes, muscle weakness, and significant cognitive impairment, experienced severe and ongoing weight loss over several months. There was no documented evidence of an admission nutritional assessment or risk assessment, and the resident's care plan was not updated in response to significant changes in her condition, including weight loss, diet order changes, or hospitalization. Orders for weekly weights and meal assistance were not consistently followed, and documentation of weights was incomplete or missing, with staff signing off on tasks that were not performed. Observations and interviews revealed that the resident was not consistently assisted with meals as ordered, despite having documented needs for supervision and assistance due to pocketing food and cognitive impairment. On multiple occasions, the resident was left with meal trays without being assisted to a sitting position or being supervised, and alternatives were not offered when meals were refused or only partially consumed. Staff were often unaware of the resident's assistance needs or the meaning of physician orders for meal assistance, and there was confusion among staff and management regarding the implementation of these orders. The facility's own policies required individualized assistance with meals and routine weight monitoring, but these were not adhered to in practice. The facility also experienced issues with record-keeping and continuity of care following a change in ownership and electronic medical record systems, resulting in missing documentation related to the resident's nutrition. The dietitian and other staff confirmed that weekly weights were not obtained as ordered and that it was difficult to get staff to complete these tasks. The resident's intake remained poor, and despite recommendations and orders for supplements and appetite stimulants, these interventions were inconsistently effective due to frequent refusals and lack of proper assistance. The cumulative effect of these failures was a significant and unaddressed decline in the resident's nutritional status.
Resident Placed on Incorrect Mechanically Soft Diet Due to Documentation Error
Penalty
Summary
A resident with a history of acute osteomyelitis, ESBL-producing E. coli infection, metabolic encephalopathy, and acute kidney failure was admitted to the facility and was mistakenly placed on a mechanically soft diet. The resident's hospital discharge summary indicated a regular diet, and the initial screening by the registered dietitian found no issues with chewing or swallowing. However, the speech therapist erroneously continued a mechanically altered diet order from a previous admission, based on incorrect information in Section K of the MDS and without current speech therapy progress notes. As a result, the resident received a mechanically soft diet that was not clinically indicated, leading to poor meal consumption, with records showing less than 50% of meals eaten on multiple occasions. The resident expressed dissatisfaction with the mechanically soft diet and relied on family to bring in food, as he did not like or eat the meals provided by the facility. The error was only identified and corrected after surveyor intervention.
Failure to Conduct Employee Reference Checks and Lack of Screening Policy
Penalty
Summary
The facility failed to complete employee reference checks prior to hiring several staff members, including two certified nursing assistants and two licensed practical nurses. Review of their employee files showed no evidence that reference checks were conducted before their employment start dates. Additionally, the facility was unable to provide an exact start date for one of the LPNs, and there was no documentation of reference checks for any of the four staff members reviewed. Interviews with the Director of Nursing and the Administrator confirmed that reference checks were not performed and that the company does not have a policy requiring them. Further review of the facility's policy titled 'Abuse Investigation and Reporting' revealed that it did not include any written procedures for screening potential staff for a history of abuse, neglect, exploitation, or misappropriation, nor did it require attempts to obtain information from previous or current employers. The lack of documented policies and procedures regarding employee reference checks had the potential to affect all residents in the facility, which had a census of 64 at the time of the survey.
Facility Fails to Provide Proper Incontinence Briefs for Bariatric Residents
Penalty
Summary
The facility failed to provide appropriately sized incontinence briefs for three bariatric residents, leading to discomfort and inadequate care. Resident #48, who has chronic respiratory failure, atrial fibrillation, and incontinence, was frequently found without the necessary 3XL incontinence briefs. Interviews with nursing staff revealed that the facility consistently ran out of these briefs, forcing staff to use ill-fitting alternatives that did not meet the resident's needs. Observations confirmed the absence of 3XL briefs in the supply room, and the resident reported discomfort due to the tight-fitting briefs. Similarly, Resident #66, with diagnoses including chronic respiratory failure and incontinence, and Resident #77, with morbid obesity and quadriplegia, also experienced a lack of appropriate incontinence briefs. Both residents were assessed as needing 3XL briefs, which were not available, leading to the use of unsuitable alternatives. Staff interviews corroborated the ongoing issue of inadequate supplies, and both residents expressed discomfort and dissatisfaction with the briefs provided. The deficiency was identified during a complaint investigation, highlighting the facility's failure to accommodate the specific needs of these residents.
Inadequate Supply of Oxygen Cannulas Leads to Deficiency
Penalty
Summary
The facility failed to ensure that oxygen tubing was changed monthly for a resident due to an inadequate supply of oxygen cannulas. This deficiency affected one resident who was admitted with diagnoses including acute respiratory failure with hypoxia, sleep apnea, mood disorder, and congestive heart failure. The resident was assessed to have minimally impaired cognition and required continuous oxygen therapy. The care plan specified that the oxygen tubing and humidifier bottle should be changed monthly and as needed, according to facility policy. Interviews with nursing staff revealed that there had been no oxygen cannulas available in the storage room for several weeks, preventing them from performing their duties effectively. An observation of the supply room confirmed the absence of oxygen cannulas, with only three tracheostomy masks available. Further observation showed that the oxygen tubing for the resident was dated over a month prior, and the resident could not recall the last time the tubing and cannula were replaced. The facility's policy on oxygen administration, which required monthly changes of tubing and cannulas, was not adhered to, leading to this deficiency.
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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 Washington Court Hou
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Court House Manor | 0.1 mi | ★★★★★ | 0 | 0 |
| St Catherines Manor Of Washington Court House | 0.2 mi | ★★★★★ | 18 | 0 |
| Copper Knoll Health & Rehab Llc | 3.1 mi | ★★★★★ | 13 | 0 |
| Autumn Years Nursing Center | 11.8 mi | — | 0 | 0 |
| Greenfield Skilled Nursing And Rehabilitation | 13.8 mi | ★★★★★ | 10 | 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.