Below 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 Cedarwood Plaza during CMS and state inspections, most recent first.
Three residents with orders for low sodium or cardiac diets did not receive their prescribed meals, as all residents were served chicken with mushroom gravy instead of the required sautéed mushrooms. This occurred despite clear physician orders and care plans, and was confirmed by staff interviews and observation. The deficiency had the potential to affect additional residents on similar therapeutic diets.
The facility did not ensure that meals were palatable or served at safe, appetizing temperatures due to malfunctioning kitchen equipment, inadequate use of thermal bases, and failure to follow recipes for seasoning. Several residents, including those with complex medical needs, received food that was cold, bland, and not in accordance with their care plans or facility policy.
The facility did not maintain the required holding temperature for mechanical soft chicken during meal service, with food temperatures falling below 135°F and not being reheated as needed. This was due to non-functional kitchen equipment and delayed repair requests, affecting multiple residents on mechanical soft diets.
A resident with an indwelling Foley catheter did not receive catheter care according to standards, as a CNA failed to check for bowel incontinence before care, used unclean surfaces for supplies, did not clean the catheter insertion site properly, and neglected hand hygiene between glove changes. These actions were inconsistent with facility policy and infection control protocols, as confirmed by staff interviews and policy review.
A resident with multiple complex diagnoses experienced a significant, unaddressed weight loss over several months. Despite care plan interventions and facility policy requiring prompt reweighting and monitoring, staff did not timely identify or respond to the resident's declining weight, and nutritional assessments failed to reflect the true extent of the loss. This resulted in continued weight decline and repeated hospitalizations.
A resident with an indwelling catheter did not receive proper infection control during care, as a CNA failed to use clean techniques, placed soiled items on the floor, did not perform hand hygiene or change gloves appropriately, and wore contaminated PPE outside the room, contrary to facility policy. These actions were confirmed by staff interviews and policy review, with the deficiency potentially affecting all residents on the unit.
Surveyors found that the kitchen was not maintained in a clean and sanitary condition, with multiple food items improperly labeled or stored, exposed and freezer-burned meat, and unsanitary equipment and fixtures. These deficiencies had the potential to affect all 104 residents in the facility.
Surveyors observed that the dumpster area was not maintained in a clean and sanitary condition, with significant debris such as used gloves, food containers, and a damaged cardboard box scattered around. The grease barrel was also left open with a stock pot of water on top. These conditions were confirmed by a dietary aide and had the potential to affect all 104 residents.
Several residents received smaller meal portions and did not receive all menu items as specified, with some items substituted or omitted entirely. Staff used incorrect scoop sizes, and some residents did not receive fruit or dessert with their meals. The dietary manager confirmed that substitutions and incorrect portion sizes occurred, affecting multiple residents and potentially impacting all except those who were NPO.
Dietary staff did not adhere to proper food handling protocols, including using a dish cloth to dry silverware instead of air-drying and assembling sandwiches with gloved hands without serving utensils. The dietary manager confirmed these actions were not in line with facility policy, which requires air-drying of equipment and use of utensils to prevent direct hand contact with food. Two residents on NPO status were not affected.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting 111 residents. Observations revealed unlabeled and undated food items, live gnats, and unsanitary conditions in the kitchen, including grime build-up and unclean tray carts. These issues were confirmed by the Dietary Manager.
The facility failed to maintain appropriate food temperatures and palatability, affecting six residents. Observations revealed that while initial food temperatures were acceptable, subsequent monitoring was lacking, resulting in food being served at inadequate temperatures. Residents expressed dissatisfaction, noting that hot foods were served cold and the overall taste was poor.
The facility failed to provide timely incontinence care to two residents, resulting in prolonged periods of discomfort. One resident, with cognitive impairment and mobility issues, was left in a soiled state for over four hours, while another resident, who was cognitively intact but required supervision, was left with saturated sheets for several hours. Staff interviews indicated that residents were checked and changed only twice per shift, contrary to the facility's policy of providing care as needed.
A facility failed to ensure staff wore appropriate PPE during wound care for a resident under Enhanced Barrier Precautions (EBP). The resident, with multiple medical conditions and dependent on staff for ADLs, required EBP due to a heel wound and indwelling devices. Despite facility policy, the RN did not wear a gown during care, acknowledging the oversight. This deficiency was noted during a complaint investigation.
A facility failed to provide a safe environment when an STNA brought an unsecured loaded firearm into the facility. A resident mistakenly took the bag containing the firearm to her room, found it, and hid it under her mattress. The firearm was later recovered by the police. The STNA was terminated for violating the facility's policy on firearms.
Failure to Provide Prescribed Low Sodium/Cardiac Diets to Residents
Penalty
Summary
The facility failed to ensure that three residents received their prescribed two-gram sodium (low sodium) and/or cardiac diets as ordered by their physicians. Medical record reviews showed that these residents had significant diagnoses such as type two diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease, and hypertensive heart disease, all of which required careful dietary management. Physician orders and care plans for these residents specifically indicated the need for low sodium or cardiac diets, and these requirements were documented in their nutritional assessments and care plans. During a review of the facility's menu and direct observation of meal service, it was found that the lunch menu for a specific day required residents on a two-gram sodium or cardiac diet to receive chicken with sautéed mushrooms instead of mushroom gravy. However, observation of the steam table and tray line revealed that no sautéed mushrooms were available, and all residents, including those on restricted diets, were served chicken with mushroom gravy. Only one resident received a different gravy due to a dislike or allergy, not due to dietary restrictions. Interviews with dietary staff and the dietary consultant confirmed that the correct menu modification for residents on therapeutic diets was not followed, and the error was attributed to oversight. Review of the facility's policy indicated that meals should be checked against the therapeutic diet spreadsheet to ensure accuracy, but this procedure was not followed, resulting in the deficiency. This issue affected three residents directly and had the potential to impact an additional six residents identified as being on similar therapeutic diets.
Failure to Provide Palatable and Properly Heated Meals
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and maintained at a safe and appetizing temperature. Observations revealed that the steam table used to keep food warm was not fully operational, with three wells not working and the steamer out of service. As a result, some food items, such as zucchini and onions, were served at temperatures as low as 101.5°F, which is below the facility's policy requirement of at least 135°F for hot foods. Additionally, the zucchini and onions were served without seasoning or margarine, and the noodles were served without the required herbs or margarine, resulting in bland and unappetizing meals. The facility also lacked enough thermal pellet bases to keep all residents' meals warm, using them only for residents on the third floor, while others received only heated plates and dome lids. Interviews with dietary staff and consultants confirmed the issues with food preparation and temperature maintenance. Staff acknowledged that the lack of operational equipment negatively affected their ability to maintain proper food temperatures. During meal service, when the kitchen ran out of noodles and mushroom gravy, trays with thermal pellets were left sitting out while more food was prepared, and these pellets were not reheated before use. Test trays prepared for surveyors confirmed that the food was served at inadequate temperatures and lacked flavor, with the zucchini and onions specifically noted as cold and tasteless, and the noodles as warm but flavorless. Several residents were directly affected by these deficiencies. One resident with a history of chronic kidney disease, weight loss, and other medical conditions reported that meals were not tasteful and described lunch as terrible. Another resident with chronic respiratory failure, diabetes, and heart disease stated that the zucchini lacked flavor and the food was at room temperature. A third resident with cancer, diabetes, and malnutrition risk described the lunch as unappetizing and not warm enough. These findings were corroborated by reviews of medical records, care plans, and facility recipes, which specified the use of seasonings and proper food temperatures that were not followed during the observed meal service.
Failure to Maintain Safe Holding Temperature for Mechanical Soft Chicken
Penalty
Summary
The facility failed to ensure that mechanical soft chicken was held at a safe temperature during lunch service, potentially affecting 18 residents who required a mechanical soft diet. Observations revealed that while most food items were initially cooked to safe internal temperatures, the mechanical soft chicken was found to be at 123.0°F during tray line setup, below the required holding temperature of 135°F. Despite other food items being reheated after low temperatures were identified, the mechanical soft chicken was not reheated and remained on the steam table. Subsequent temperature checks showed the mechanical soft chicken had dropped further to 109.2°F and then 108.7°F, still below the safe threshold, before it was finally reheated after surveyor intervention. Interviews with dietary staff and consultants indicated that several wells of the steam table and the steamer were not fully operational, which had been an ongoing issue for approximately a week and a half. The lack of functioning equipment hindered the facility's ability to maintain safe food temperatures. Documentation from equipment repair companies showed that repairs had not been promptly requested or completed, and there was no evidence that parts were unavailable as previously claimed by staff. The facility's policy required hot foods to be held at or above 135°F, but this standard was not met for the mechanical soft chicken during the observed meal service.
Failure to Perform Proper Catheter and Incontinence Care Increases Infection Risk
Penalty
Summary
A deficiency was identified when staff failed to perform catheter care according to appropriate standards of practice, increasing the risk of contamination and urinary tract infection. Review of a resident's medical record showed the individual had multiple diagnoses, including neuromuscular dysfunction of the bladder, and required an indwelling Foley catheter with care every shift. The care plan specified the need for enhanced barrier precautions and outlined that incontinence care should be provided prior to catheter care if the resident was soiled, to prevent contamination. During direct observation, a CNA did not check for bowel incontinence before starting catheter care and used washcloths that were placed directly on an unclean overbed table without a barrier. The CNA did not use a method to ensure a clean part of the washcloth was used for each stroke, did not use soap, and failed to clean the area around the catheter insertion site or the catheter itself. After incomplete catheter care, the CNA left and re-entered the room, changed only one glove without performing hand hygiene, and then performed incontinence care. The same soiled gloves were used to reposition the catheter tubing and fasten a clean brief, further increasing the risk of contamination. Interviews with staff confirmed that the observed practices did not align with facility policy or standard infection control procedures. Policies required the use of clean basins and washcloths, cleaning from the meatus outward with a clean part of the cloth for each stroke, and performing hand hygiene between glove changes. The failure to follow these procedures was corroborated by staff interviews and review of facility policies, which emphasized the importance of proper hand hygiene and cleaning techniques to prevent infection.
Failure to Timely Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to timely address a significant weight loss in a resident with multiple complex medical conditions, including schizophrenia, severe sepsis with septic shock, adrenocortical insufficiency, depression, and thyrotoxicosis. The resident's care plan identified altered nutritional status and significant weight loss, with interventions such as monitoring intake, providing supplements, and alerting nursing or dietitian staff if intake was inadequate. Despite these interventions, the resident experienced a substantial weight loss over a short period, dropping from 192 pounds to 146 pounds between early May and July, as documented in both facility and hospital records. The facility's records showed that the resident's weight was stable until early May, after which there was a marked decline. The resident was hospitalized for altered mental status, and hospital records confirmed a significant weight loss during the stay. Upon return to the facility, further weight loss was documented, but there was no timely documentation or intervention addressing the ongoing weight loss between May and July. The quarterly nutritional assessment did not reflect the hospital or recent facility weights, and incorrectly noted no significant weight loss, despite meal intake averaging only 50% and the resident refusing supplements. Interviews with staff revealed that standard procedures for monitoring significant weight loss, such as obtaining reweights and initiating weekly weights, were not followed in a timely manner. The dietitian and DON confirmed that the resident's weight loss was not addressed promptly, and the facility's policy requiring reweights within 48 hours of a five-pound deviation was not implemented. The lack of timely assessment and intervention contributed to the resident's continued decline, as evidenced by further weight loss and subsequent hospitalizations.
Failure to Follow Infection Control Procedures During Catheter and Incontinence Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control procedures were followed during care for a resident with an indwelling urinary catheter. During observation, a certified nurse aide (CNA) performed catheter and incontinence care without adhering to established protocols. The CNA used wet washcloths placed directly on an unclean overbed table, did not use a barrier or basin, and failed to clean the catheter insertion site appropriately. The same gloves were used throughout the care process, including handling clean and soiled items, and the CNA did not change gloves or perform hand hygiene at appropriate intervals. Additionally, the CNA exited and re-entered the resident's room while still wearing the same gown and gloves used during care, and handled clean items after touching soiled materials without proper glove changes or hand hygiene. Further deficiencies were observed in the handling of soiled linens and personal protective equipment (PPE). The CNA placed soiled washcloths and briefs on the floor next to the resident's bed and in the bathroom doorway, rather than immediately disposing of them in appropriate bags. The CNA also failed to have trash bags ready prior to care, as required by facility policy. After completing care, the CNA walked through the hallway and accessed clean linen and medication carts while still wearing the soiled gown and gloves, further breaching infection control protocols. Only after these actions did the CNA perform hand hygiene and properly dispose of PPE and soiled items. Interviews with staff confirmed that the observed practices were inconsistent with facility policies and standard infection control procedures. Staff acknowledged that basins and clean washcloths should be used, soiled items should never be placed on the floor, and PPE must be removed before exiting a resident's room. Hand hygiene was also confirmed as a required step before and after glove changes. Review of facility policies corroborated these requirements, including proper cleaning of the catheter insertion site, appropriate disposal of soiled linens, and correct donning and doffing of PPE. The failure to follow these procedures was observed to affect one resident directly and had the potential to impact all residents on the unit.
Deficient Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, labeling, and cleanliness. During an inspection, it was found that several food items in the walk-in cooler, including a spiral ham, chopped onion, diced turkey, butter, bacon bits, and beef fat, were either not labeled or not dated. In the walk-in freezer, beef slabs were left exposed on a cardboard box, showing significant freezer burn, and cookie dough bites were stored in an open plastic bag. These findings were confirmed by a dietary aide at the time of discovery. Further inspection of the kitchen revealed unsanitary conditions, including multiple light fixtures containing dust, debris, and dead bugs. The six-burner cooktop had a thick layer of black food buildup around and underneath the burners, and the microwave used for resident food was extremely dirty with brown residue. The facility's policy on food preparation and storage was reviewed and found to be undated, but it stated that food items should be kept free of harmful organisms and substances. The observed deficiencies had the potential to affect all 104 residents in the facility.
Improper Disposal and Sanitation of Dumpster Area
Penalty
Summary
The facility failed to maintain the dumpster area in a clean and sanitary condition, as observed during a survey with a dietary aide. Significant amounts of debris, including plastic gloves, used plastic silverware, paper plates with food residue, brown bags, and various plastic items were found scattered to the left of the dumpster. In front of the dumpster, a cardboard box was observed on the ground, appearing to have been run over multiple times by vehicles. To the right of the dumpster, the facility's grease barrel was found open to the air with a stock pot of water placed on top. These findings were confirmed by staff during the survey. This deficiency had the potential to affect all 104 residents residing in the facility, as noted in the facility census at the time of the survey.
Failure to Provide Correct Menu Items and Serving Sizes
Penalty
Summary
The facility failed to ensure that residents received correct serving sizes and all menu items as specified on the posted menu. Observations and interviews revealed that several residents received smaller portions than required, and some menu items were substituted or omitted entirely. For example, residents reported receiving small portions at mealtimes and not knowing what was on the menu prior to receiving their meals. Review of the menu indicated specific serving sizes and items for different diet types, but during meal service, staff used incorrect scoop sizes, resulting in smaller portions. Additionally, some menu items such as coleslaw and apple slices were replaced with chips, cottage cheese with fruit, and applesauce cups, which were also served in smaller portions than required. Further observations showed that some residents did not receive fruit cups or dessert with their meals, and staff confirmed these omissions. The dietary manager acknowledged that substitutions were made due to unavailable items and verified that the portions served were not consistent with the menu requirements. These deficiencies affected multiple residents and had the potential to impact all residents except those who were NPO (nothing by mouth). The findings were based on direct observation, record review, and staff and resident interviews.
Failure to Follow Sanitary Food Handling and Serving Procedures
Penalty
Summary
Dietary staff failed to follow proper food handling and sanitation procedures during meal service. One dietary aide was observed using a dish cloth to dry silverware, rather than allowing them to air dry as required by facility policy, and then placed the dried silverware into a holder. The aide confirmed she was unaware that this method was not permitted. Additionally, during lunch tray preparation, another staff member was seen assembling sandwiches by handling bread, deli meat, lettuce, and tomato with the same pair of gloved hands, without using serving utensils as expected. The dietary manager confirmed that serving utensils should have been used. The facility's policy specifies that all food service equipment should be cleaned, sanitized, air-dried, and that tongs or other utensils should be used to avoid direct hand contact with food. Two residents were identified as receiving nothing by mouth per physician orders, and thus were not affected by the meal service.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions, potentially affecting 111 residents who received meals from the kitchen. During an observation, several issues were noted in the facility's kitchen. In the main freezer, bread and French fries were stored in clear plastic bags without labels or dates. In the dry food storage area, an open bag of powdered sugar was wrapped in ripped plastic wrap, spilling out when handled, and other bread items lacked labels or dates. A bag of tortilla shells was found with an expired use-by date, and an unlabeled container with a brown substance was stored without a label or date. Live gnats were observed near the bread and dish machine, and wet oven trays were stored with clean pots and pans. Additionally, there was a heavy build-up of black grime on the floor under the dish machine and dried food particles and grime on the walls where they met the floor throughout the kitchen. Two tray carts used for transporting resident food had a large amount of dried white substance resembling dried milk, indicating they were not kept clean and sanitary. These observations were confirmed by the Dietary Manager during an interview, highlighting the facility's non-compliance with sanitary food storage and preparation standards.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. During an observation of the kitchen food production and lunch tray line meal service, it was noted that while all hot foods initially reached acceptable temperatures above 165 degrees Fahrenheit, a second set of temperatures was not taken to monitor the food throughout the service. A test tray was prepared and sent to the dining room, where the temperatures were taken by the Dietary Manager. The ham slice was found to be 106 degrees Fahrenheit, barely warm to taste, the cold potato salad was 75 degrees Fahrenheit, not cold, and the mixed vegetables were 136 degrees Fahrenheit, only warm. These temperatures were verified by the Dietary Manager. Interviews with six residents revealed dissatisfaction with the food service. Residents reported that hot foods were served cold, the food did not taste good, and some even resorted to ordering food from outside due to the poor quality. The facility's policy on food temperatures at the point of service requires that hot food items be cooked, held, and served at appropriate temperatures, with frequent monitoring to ensure safe food holding temperatures. This deficiency was investigated under Complaint Number OH00162967.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to two residents, resulting in prolonged periods of discomfort and potential health risks. Resident #10, who was moderately cognitively impaired and required substantial assistance due to hemiplegia and hemiparesis, was left in a soiled state from before 10:00 A.M. until after 2:00 P.M. The resident had been in a chair since before 7:00 A.M. and was not checked or changed until CNA #335, with the help of LPN #312, transferred her to bed. The resident's brief was found to be completely saturated with urine and stool, indicating a significant delay in care. Similarly, Resident #74, who was cognitively intact but required supervision for toileting due to overflow incontinence and muscle weakness, was left sitting in a chair with saturated sheets from 8:45 A.M. until after 1:00 P.M. The room had a strong odor of urine, and the resident reported having asked for assistance hours earlier. Staff interviews revealed that residents were typically checked and changed only twice per shift, which was insufficient for the needs of these residents. The facility's policy required incontinence care to be provided as needed, but this was not adhered to, leading to the deficiency.
Failure to Use PPE During Wound Care Under EBP
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) when caring for a resident on the South unit who was under Enhanced Barrier Precautions (EBP). This deficiency was observed during wound care for Resident #51, who had a history of type two diabetes mellitus, anoxic brain damage, urinary tract infection, acute respiratory failure with hypoxia, and other infections. The resident was dependent on staff for all Activities of Daily Living (ADLs) and had orders for EBP due to a heel wound, a foley catheter, and tube feedings. Despite these orders, the Registered Nurse (RN) performing wound care did not wear a gown, which was required for high-contact resident care activities under EBP. The RN, who was also the facility's Wound Care Nurse and Infection Preventionist, acknowledged the oversight during an interview, stating that she forgot to put on her gown. The facility's policy on Enhanced Barrier Precautions, last reviewed in November 2023, clearly stated that gowns and gloves are to be used for high-contact resident care activities for residents with wounds or indwelling medical devices. This incident was identified as a deficiency during the investigation of a complaint, highlighting a lapse in adherence to infection control protocols.
Unsecured Firearm Incident in LTC Facility
Penalty
Summary
The facility failed to provide a safe environment free from potential accident hazards when a State tested Nursing Assistant (STNA) brought an unsecured loaded firearm into the facility. The firearm, along with additional rounds of ammunition, was left wrapped in a fleece vest and placed in a clear plastic bag on a cart in the 3 North Hallway. This area was accessible to residents, and one resident mistakenly took the bag to her room, found the firearm, and placed it under her mattress. The facility was unaware of the firearm's location until the resident informed another STNA, who then notified the local police department. The police took possession of the firearm and ammunition. The incident involved Resident #64, who had diagnoses including depression, anemia, and uncomplicated alcohol dependence. The resident had mild or no cognitive impairment but experienced daily occurrences of feeling down or depressed. A psychiatry note indicated that the resident was alert and oriented to person and place but had poor memory, insight, and judgment. The resident found the unattended bag on the cart, believed it was hers, and took it to her room, where she discovered the loaded firearm and hid it under her mattress. STNA #563 admitted to bringing the loaded firearm to work for personal protection due to working nights and taking the bus. The STNA stored the firearm with his personal belongings in a bag at his workstation on the third floor. The STNA noticed the bag was missing after returning from lunch and notified a nurse. The facility staff, including the Director of Nursing (DON) and Unit Manager (UM), conducted searches of the facility but were unable to locate the firearm until Resident #64 informed STNA #592 about it. The facility's policy prohibits firearms and other weapons on the premises, and STNA #563 was subsequently terminated for violating this policy.
Removal Plan
- STNA #563 informed Unit Manager (UM) #628 his coat and firearm were missing from the 3 North Hallway. UM #628 immediately notified the DON of the missing firearm.
- The DON notified the Administrator of the missing firearm.
- The Administrator notified the local police department (LPD) of the missing firearm.
- The DON assigned managers to search the first, second, and third floors of the facility for the missing firearm.
- The Local Police Department (LPD) arrived at the facility. The Administrator and UM #628, along with the responding officer, reviewed camera surveillance to determine if the missing firearm could be seen being removed from the last known location. The cameras did not assist in identifying who may have removed the bag carrying the missing firearm.
- The DON and Administrator assigned new areas for managers to search for the missing firearm, including dietary, the basement, and the exterior of the facility.
- The DON and Maintenance Supervisor (MS) #618 searched the garbage for the missing firearm.
- A second officer from the LPD arrived and obtained a statement from STNA #563 regarding the missing firearm.
- STNA #592 located the missing firearm in Resident #64's room. The LPD took immediate possession of the firearm.
- STNA #563 was suspended pending the investigation into the firearm he brought into the facility.
- An Ad Hoc QAPI was held with the Administrator, DON, Business Office Manager (BOM) #537, Cook #639, Receptionists #535 and #583, Corporate Admission (CA) #701, Dietary Tech (DT) #702, Assistant Business Office Manager (ABOM) #565 and Admissions Director (AD) #703 to review the facility policy on Firearms and Other Weapons. The facility prohibits employees, residents, visitors, vendors, or others from possessing firearms or other weapons while in/on facility premises.
- The DON notified Medical Director (MD) #704 of the incident involving the firearm.
- Chief Clinical Officer (CCO) #705 re-educated the DON on the facility's policy on firearms and other weapons.
- The DON and CCO #705 educated all staff, including five activities staff, two admissions staff, two business office staff, one central supply staff, 25 dietary staff, seven hospitality aides, 12 housekeepers, two laundry staff, 27 Licensed Practical Nurses (LPN), one maintenance staff, three medication technicians, three social workers, two therapists, three receptionists, 10 Registered Nurses (RN) and 37 STNAs related to the facility firearm policy. Education was provided in person for staff at the facility and over the phone for those off duty.
- UM #628 completed a skin assessment for Resident #64. No new areas of concern were identified.
- The DON or designee completed an assessment of all residents. Residents were safe and at baseline. No psychosocial concerns were identified.
- The Administrator placed new, more prominent signage at the entrances prohibiting firearms in the facility.
- Maintenance Staff (MS) #618 changed door codes due to the suspension of STNA #563.
- The DON or designee implemented a system to audit five random staff four times weekly for four weeks then three random staff weekly for eight weeks to ensure knowledge of the facility's firearms policy. Findings would be reviewed in weekly QAPI meetings to ensure compliance with the policy.
- Regional Director of Operations (RDO) #706 notified STNA #563 of termination of employment due to not following the facility policy on firearms.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Cleveland Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Judson Park | 0.8 mi | ★★★★★ | 0 | 0 |
| University Manor Health & Reha | 0.8 mi | ★★★★★ | 0 | 0 |
| The Gardens Of Fairfax Health Care Center | 1.7 mi | ★★★★★ | 14 | 0 |
| Candlewood Healthcare And Rehabilitation | 1.8 mi | ★★★★★ | 0 | 0 |
| Crawford Manor Healthcare Center | 2 mi | ★★★★★ | 2 | 0 |
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