Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and mobility limitations sustained an unwitnessed fall in a hallway, reported hitting the head, and later was found to have a left proximal humerus fracture. Dietary staff discovered the resident on the floor, were unable to locate a nurse, and lifted the resident into a rolling desk chair before nursing staff assessed the resident, while CNAs and an RN later confirmed hearing that dietary staff had assisted the resident from the floor. Although dietary aides reported completing witness statements, the facility’s investigation included only statements from a CNA and an LPN who was on break at the time, and omitted the dietary staff accounts and any examination of the lack of RN assessment prior to moving the resident, contrary to facility policy requiring prompt, comprehensive incident investigations.
A resident with a stage 4 right hip pressure ulcer had physician orders for wound vac therapy at 120 mmHg suction, with specific cleaning and dressing change instructions. A wound consultant later recommended increasing the wound vac suction to 150 mmHg, but this change was never incorporated into the physician’s orders or the Treatment Administration Record. As confirmed by the DON, the consultant’s recommendations were not updated in the clinical record, resulting in the resident continuing on the original wound vac settings contrary to the consultant’s recommendation.
Inadequate Resident Activity Program: Review of the activity calendar showed only one weekend activity and no organized activities after 2:00 p.m. for most units, while residents stated they wanted weekend and evening activities and had asked for them. The Activity Director said staff were present on weekends but did not hold organized activities, and evening activity coverage was focused on the dementia unit, leaving no one else to lead activities for other residents.
Ice machine drain pipe lacked a required air gap in the third floor pantry. Surveyors observed the pipe running directly into the floor drain with no air gap, and the Maintenance Director confirmed the condition and stated that an air gap should have been present.
A resident with a PEG tube and an order for Juven if she ate less than 50% of a meal had inconsistent documentation of meal intake and tube feed administration. Nurse aide task records showed several meals under 50%, but the MAR reflected different intake percentages and no tube feed on those occasions. Staff interviews confirmed that intake was first written on a paper sheet for the LPN to review, and the DON acknowledged the mismatch between the aide documentation and the MAR.
A resident’s room had multiple areas of chipped and peeling paint on the walls around the bed, and the Maintenance Director confirmed the walls needed repair to ensure a homelike environment. The resident was cognitively intact, needed minimal assistance, and had dx including Alzheimer’s disease and colon cancer.
Failure to provide ordered pain medication: two residents with chronic pain did not receive prescribed Lidocaine 4% patches as ordered. Nursing notes showed the patches were unavailable on multiple occasions, and one resident reported the facility had run out of patches multiple times. The DON confirmed the medication was not given because the facility ran out and staff did not notify the DON or MD.
Cold and Unpalatable Meal Service: Residents reported that meals delivered to rooms and dining areas were served cold, and one resident said the food was often cold and bland. During lunch observation, a test tray took 18 minutes to reach the 3rd floor, and the spaghetti and meatballs and vegetable blend were cool to taste and not palatable. The Corporate Dietary Manager confirmed that food should be served at proper and palatable temperatures.
Failure to obtain and document informed consent for psychotropic meds: A cognitively intact resident with depression and bipolar disorder had Seroquel doses increased without documented advance discussion of risks, benefits, or alternatives; another cognitively intact resident had Cymbalta increased without a signed informed consent from the representative; and a resident with cognitive impairment and non-Alzheimer's dementia was started on Zyprexa and Seroquel without documented advance notification. The DON confirmed the missing documentation.
A resident who was cognitively intact and needed staff help with daily care slid out of her electric wheelchair and onto the floor. Although the EHR indicated her daughter was to be contacted at all times for any change, there was no documented evidence that the daughter was notified after the fall. The resident said she was upset, and the DON confirmed the daughter was not notified.
Required admission and annual MDS assessments were not completed on time for four residents. Two residents had admission MDSs completed late, and two residents had annual MDSs completed after the due date. The DON confirmed the assessments were not completed within the required time frames.
A facility failed to keep accident hazards minimized for two residents. One resident, identified as a fall risk and cognitively intact, had a reacher tool that was placed out of reach even though her care plan called for personal items and the reacher to be within reach. Another resident with a femur fracture, difficulty walking, and generalized muscle weakness was transported in a chair without ordered leg rests; the nurse aide said the rests were in therapy, and the DON confirmed they should have been used.
Medication Storage and Labeling Deficiencies: Surveyors found an expired insulin pen and an open insulin pen that was not dated in a medication cart, along with a box of Lorazepam syringes stored in an unlocked refrigerator with the narcotic box not permanently affixed. An LPN and the DON confirmed the issues, and the facility policy required opened medications to be dated and stored medications to be kept in locked compartments.
QAPI Committee Failed to Sustain Compliance With Repeated Deficiencies: The facility’s QAPI committee did not maintain ongoing compliance with repeated deficiencies involving safety/accidents, medication labeling and storage, palatable food, and sanitary food practices. Prior plans of correction relied on audits and QAPI review, but the current survey still cited noncompliance under F689, F761, and F812.
A resident with active C. diff had orders for contact precautions and was on Vancomycin. During an observation, a nurse aide entered the room without a gown and provided perineal care and brief change while wearing only gloves. The aide said she did not know the resident was on contact precautions, and the DON confirmed a gown should have been worn.
Failure to Complete Required Nurse Aide In-Service Training: The facility did not ensure that one of four nurse aides reviewed completed the required annual in-service training. Review of the aide’s personnel and continuing education records showed she lacked the required 12 hours of annual training, and the DON confirmed the deficiency in interview.
Three severely cognitively impaired residents, all dependent on staff and diagnosed with dementia, were left in a day room where the temperature exceeded the facility's policy, reaching 83.9°F. Observations showed one resident with a flushed face and another with a clammy appearance. Staff confirmed that the room's air conditioning unit was not functioning, and the issue had been identified in a recent audit.
Essential equipment, specifically PTAC units in resident rooms, were found with filters covered in thick debris. The Maintenance Director confirmed filters had not been cleaned as required by manufacturer instructions, believing they only needed cleaning twice a year, and had not performed this maintenance since starting employment.
A resident with a physician's order for a tooth extraction did not have an appointment scheduled with an oral surgeon, resulting in the procedure not being completed. The resident continued to experience tooth sensitivity, and the DON confirmed that the required dental appointment was never made.
A resident with diabetes and no natural teeth was documented as receiving denture care, despite not having dentures due to their loss. Nurse aide documentation inconsistently recorded denture care as provided or refused, and the DON confirmed the records did not accurately reflect the resident's status.
A resident who required two-person assistance for bed mobility was cared for by a single nurse aide who did not review the care plan or Kardex prior to providing care. As a result, the resident fell from bed and sustained multiple fractures and a scalp laceration. The aide had previously received education on abuse/neglect policies and care plan review, but failed to follow established protocols.
A resident who required two staff for bed mobility, due to recent hip surgery and confusion, was assisted by only one nurse aide who had not reviewed the care plan. During a bed change, the resident fell out of bed, sustaining facial and neck fractures and a scalp laceration. The DON confirmed the aide did not follow the care plan, leading to the fall and injuries.
The facility did not properly store or monitor food in resident refrigerators, with multiple food items kept past their use-by dates and refrigerator temperatures exceeding safe limits. Staff failed to document temperatures as required, and the dietary department did not ensure timely removal of expired food, as confirmed by interviews and observations.
The facility failed to maintain its cooking facilities according to NFPA 101 standards, as it lacked documentation for the semi-annual testing and maintenance of the kitchen fire suppression system. This deficiency, affecting one of nine smoke compartments, was confirmed during an interview with the DON and Maintenance Director.
The facility failed to maintain the automatic sprinkler system in one location, affecting one of nine smoke compartments. Two sprinkler heads above the dryers in the Laundry Room were found dirty and dusty, potentially affecting their activation. This deficiency was confirmed by the DON and Maintenance Director.
Cedarwood Rehabilitation and Healthcare Center's Emergency Preparedness Plan was found deficient due to missing updated names and contact information for staff and resident physicians. This was confirmed by the facility's leadership during a survey, indicating a lapse in maintaining essential documentation for emergency situations.
A facility failed to follow physician's orders for a resident with renal failure requiring dialysis. The resident was prescribed 210 mg of Auryxia five times a day, but was only receiving it three times daily. This was confirmed by the DON, indicating a failure in medication administration as per the physician's orders.
The facility failed to follow physician's orders for enteral feedings for three residents. One resident did not have the amount of Jevity 1.5 documented, another had improper verification of gastric residual volume and lacked weight monitoring, and a third had residual volume checks documented incorrectly. The DON confirmed these deficiencies.
The facility failed to serve palatable food, as residents reported receiving cold meals. Observations during a lunch service showed that food temperatures were below the required 130 degrees Fahrenheit, with ground sausage, noodles, and broccoli served at 120 degrees Fahrenheit. The Dietary Manager confirmed the need for proper food temperatures.
The facility failed to store and prepare food according to professional standards, with open and undated food items found in the resident refrigerator and improper dishwashing practices observed. The dishwasher did not reach the required sanitization temperature, and a dietary aide did not wash hands between handling dirty and clean dishes, as confirmed by staff interviews.
A resident, who required a two-person assist for transfers due to arthritis and a knee arthroplasty, was improperly transferred by a nurse aide alone, resulting in shoulder pain. Despite prior education on care plans, the aide did not verify the transfer status, leading to neglect as per facility policy.
The facility failed to provide written notification to the responsible parties and Ombudsman for two residents transferred to the hospital. One resident, cognitively intact, was sent for evaluation after lab results, while another, cognitively impaired, was transferred due to being diaphoretic and hard to arouse. In both cases, there was no documented evidence of written notice, confirmed by the DON.
The facility failed to notify two residents or their representatives about the bed-hold policy during hospital transfers. One resident, cognitively intact, was sent to the hospital for evaluation, while another, cognitively impaired, was transferred due to a medical condition. The DON confirmed the lack of documentation for these notifications.
A facility failed to create a comprehensive care plan for a resident's use of an anti-coagulant medication. Although the resident was receiving Eliquis as prescribed, there was no documented care plan addressing its use. The DON confirmed the omission, acknowledging the need for an individualized plan.
A facility failed to update a resident's care plan after a PICC line was removed, as confirmed by the DON. The resident, who was cognitively intact and required substantial assistance, initially had a PICC line for antibiotic administration. Physician's orders later instructed for the PICC line removal, which was observed to be completed, but the care plan was not updated to reflect this change.
A resident received an incorrect dosage of Lexapro due to a failure to clarify a confusing physician's order. The order indicated 10 mg but instructed to give two tablets for a total of 15 mg. The resident, who was cognitively impaired, received 15 mg on two consecutive days. An LPN acknowledged the confusion, and the DON confirmed the need for clarification.
Two residents experienced inadequate supervision and assistance during transfers. One resident was transferred using a mechanical lift without engaging the brakes, contrary to policy. Another resident, requiring a two-person assist, was transferred by a single aide, resulting in shoulder pain. Both incidents highlight lapses in following established care protocols.
The facility failed to discard expired insulin pens in two medication carts, as required by policy and manufacturer's instructions. A Lantus pen for a resident on the third floor and a Lispro pen for another resident on the second floor were found beyond their 28-day expiration period. This was confirmed by nursing staff and the DON.
The facility did not follow its planned menu, as residents reported not always receiving the meals listed. On a specific day, a lemon brownie was supposed to be served for lunch, but a blonde brownie was provided instead. The Dietary Manager confirmed the substitution was due to the absence of a recipe for the lemon brownie.
The facility's QAPI committee failed to address recurring deficiencies, including issues with care plans, quality of care, professional standards, accident hazards, and food service. Despite plans of correction involving audits and committee reviews, compliance was not maintained.
The facility failed to maintain comfortable temperatures in the fourth floor dining room, with temperatures observed between 60 and 70 degrees Fahrenheit. The Maintenance Director noted that closed doors prevented heat circulation, and the HVAC company identified open dampers allowing cold air inside. Once addressed, temperatures returned to normal.
A facility failed to notify a resident's family about a new order for a bladder/renal ultrasound, despite the resident's cognitive impairment and dementia diagnosis. The family was unaware of the order and expressed a desire to be informed about the results. The deficiency was confirmed by the DON, who acknowledged the lack of documentation regarding the notification.
A facility failed to maintain a clean environment for a resident with coronary artery disease, heart failure, and asthma. A fan, belonging to the facility, was observed blowing directly on the resident with a significant amount of dirt and debris on its blade cover. This was confirmed by staff, including the Housekeeping Aide, Infection Preventionist, Housekeeping Manager, and DON, who all acknowledged that the fan should have been clean but was not.
A facility failed to maintain a resident's ability to perform ADLs and ambulate due to the absence of a restorative nursing program. Despite recommendations following therapy sessions, no program was developed or implemented, leading to a decline in the resident's functional abilities.
A resident, who was cognitively intact and had a fracture, anxiety, and depression, experienced a fall during a transfer due to a nurse aide not following the care plan. The aide transferred the resident without the required sit-to-stand lift and assistance of two staff members, based on a previous comment by an LPN, leading to the resident being lowered to the floor.
A facility failed to obtain weekly weights for a resident with significant weight loss, as recommended by the dietician. The resident, who was cognitively impaired and diagnosed with protein calorie malnutrition, required substantial assistance with care needs. Despite the dietician's recommendation for weekly weight monitoring to guide nutritional interventions, no evidence was found that these weights were obtained or monitored. The DON confirmed the absence of physician's orders for the weights, leading to this deficiency.
A facility failed to obtain laboratory specimens as ordered for a resident with multiple health issues, including pulmonary fibrosis and respiratory failure. Despite physician orders for bloodwork, the resident refused the tests on multiple occasions, and there was no documented evidence that the bloodwork was attempted or obtained on the final scheduled date. The DON confirmed the lack of documentation.
A facility failed to follow its planned menu, serving a resident a meal that did not match the advertised menu items, without notifying the resident of the changes. The Dietary Manager confirmed the discrepancy and acknowledged that residents were not informed of the menu changes, which is against the facility's policy.
The facility failed to serve food at appropriate temperatures, as observed during a test tray evaluation. The food cart left the kitchen and arrived on the second floor, with the last resident tray delivered and tested. The temperatures of the food items, including casserole, carrots, coffee, milk, and lemonade, did not meet the facility's policy standards for safe food handling. The Dietary Manager confirmed the deficiency and noted the lack of hot plates to maintain food warmth.
The facility did not ensure dietary staff wore appropriate hair coverings, as required by policy. Observations revealed the Dietary Manager and a dietary worker handling food with uncovered hair and sideburns. The Dietary Manager confirmed the failure to comply with the hair restraint policy.
Failure to Thoroughly Investigate Resident Fall and Involve All Witnesses
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of a resident fall to rule out abuse or neglect. Facility policy required the nurse supervisor/charge nurse and department director or supervisor to promptly initiate and document an investigation of any accident or incident, including circumstances, witness names and accounts, and other pertinent data, with review by the safety committee. Resident 4 had moderate cognitive impairment, used a wheelchair, and had diagnoses including difficulty walking and generalized muscle weakness. On March 21, 2026, nursing documentation indicated the resident sustained a fall in the hallway, reported hitting his head, complained of severe left shoulder pain, and had a hematoma to the back of the head; the family requested transfer to the emergency department for evaluation. Multiple staff interviews revealed that dietary staff, not nursing staff, first encountered the resident on the floor and physically assisted him before a nurse assessed him, but this information was not fully captured in the facility’s investigation. Nurse Aide 1 and Nurse Aide 2 reported that kitchen/dietary staff had picked the resident up off the floor, and Nurse Aide 3 stated she was told by a kitchen staff member that a resident was on the floor; when she arrived, the resident was already in a rolling desk chair, and she later assisted in transferring him to his wheelchair and submitted a witness statement. Dietary Aide 5 and Dietary Aide 6 each confirmed that they found the resident on the floor, could not locate a nurse, and together lifted him from the floor to a desk chair, with both indicating they completed witness statements. Registered Nurse 4, who was on another floor at the time of the fall, later assessed the resident in his wheelchair, noted he was guarding his arm, crying out in pain, and had hit his head, and sent him to the emergency room. Despite these accounts, the facility’s written investigation of the unwitnessed fall included only witness statements from Nurse Aide 2 and LPN 7 and did not contain statements from the dietary aides who actually assisted the resident from the floor. Nurse Aide 2’s statement described finding the resident already in a wheeled desk chair and transferring him to his wheelchair, while LPN 7’s statement focused on environmental conditions and resident behaviors around the time of the incident and acknowledged she was on break when the fall occurred, returning after RN 4 was already assessing the resident. An orthopedic consultation later documented that the resident had a left proximal humerus fracture after a fall on cement. The Director of Nursing confirmed she did not obtain witness statements from dietary staff because she did not believe they would have assisted the resident in that way and also acknowledged she did not investigate the lack of RN assessment prior to the resident being moved to a rolling desk chair, despite the administrator’s statement that all staff were trained to report resident changes in condition to a nurse.
Failure to Implement Wound Consultant’s Recommendation for Wound Vac Settings
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure that wound consultant recommendations were reviewed with and incorporated into the attending physician’s orders for a resident. The resident’s annual MDS assessment dated February 24, 2026, documented that the resident was cognitively intact and had a stage 4 pressure ulcer on the right hip. Physician’s orders dated March 10, 2026, directed staff to clean the right hip wound and surrounding tissue with soap and warm water, rinse with saline, and apply a wound vac, ensuring black foam was placed into the tunneling, with dressing changes scheduled for Monday, Wednesday, and Friday, and suction set at 120 mmHg. A wound consultant note dated March 20, 2026, documented that the same resident’s stage 4 right hip pressure ulcer required a change in wound vac suction from 120 mmHg to 150 mmHg. Review of the resident’s March 2026 Treatment Administration Record showed that, as of March 31, 2026, the recommended change in wound vac suction had not been initiated. In an interview on March 31, 2026, at 12:25 p.m., the Director of Nursing confirmed that the wound care recommendations made by the wound care clinic on March 20, 2026, had not been updated in the resident’s clinical record as of that date, resulting in the failure to meet professional standards of nursing services as required by state regulations.
Inadequate Resident Activity Program
Penalty
Summary
The facility failed to provide adequate, ongoing activities designed to meet residents’ needs. Review of the February 2026 activity calendar showed only one Sunday evening activity, which was for the Super Bowl, and no other organized weekend activities. The calendar also showed no organized activities after 2:00 p.m. for any unit other than the dementia unit, where a 4:00 p.m. activity called tray pass was scheduled. During a group interview on February 2, 2026, residents stated they wanted organized activities on weekends and in the evenings. They reported that organized activities ended at 2:00 p.m. every day and that there were no organized activities on weekends, despite having asked for them. The Activity Director stated on February 3, 2026, that activity staff were present on Saturday and Sunday for four hours but did not hold organized activities because there had been no interest in the past and she did not believe many residents would participate. She also stated that an activity aide remained in the facility until around 8:00 p.m. most nights but focused on the dementia unit from 4:00 p.m. on due to increased falls and distraction activities there, leaving no one else to hold evening activities for other residents.
Ice Machine Drain Pipe Lacked Required Air Gap
Penalty
Summary
The facility failed to prepare and store ice under sanitary conditions for one of four ice machines located in the third floor pantry. During observation on February 4, 2026 at 10:41 a.m., the ice machine’s drain pipe was seen traveling directly into the drain hole with no air gap present. During an interview later that morning, the Maintenance Director confirmed that the drain pipe from the third floor pantry ice machine was in direct contact with the floor drain, that there was no air gap, and that an air gap should have been present between the end of the pipe and the floor drain.
Inconsistent meal intake documentation and MAR charting
Penalty
Summary
Clinical records were not maintained in a complete and accurately documented manner for one resident who was cognitively intact and had a PEG tube. The resident had a physician order for 240 cc of 1.5 Juven three times a day if she ate less than 50% of a meal. A quarterly MDS dated January 13, 2026, identified the resident’s condition and tube feeding status, and the facility policy required documentation to be concise, accurate, complete, and objective. Review of the nurse aide task documents for January 2026 showed multiple meals where the resident ate less than 50%, including breakfast, lunch, and dinner entries on several dates. However, the MAR did not match those entries and showed different percentages eaten on those same dates, with tube feeds not given on the documented occasions. During interviews, a nurse aide stated that percent eaten was first documented on a paper sheet at the nurses station for the LPN to review before charting, and the LPN stated she used that sheet to determine the amount eaten and sometimes collected the tray herself and documented the percentage eaten. The DON confirmed that the nurse aide documentation of the resident’s percent eaten did not match the MAR documentation and should have.
Chipped and Peeling Paint in Resident Room
Penalty
Summary
The facility failed to provide a clean and homelike environment for Resident 43. The facility policy dated January 27, 2026 stated that residents are to be provided with a safe, clean, comfortable, and homelike environment and encouraged to use personal belongings to the extent possible. Resident 43’s admission MDS dated December 26, 2025 indicated the resident was cognitively intact, required minimal assistance for care needs, and had diagnoses including Alzheimer’s disease and colon cancer. During an observation of the resident’s room on February 2, 2026, surveyors found multiple quarter-sized to half-dollar-sized areas of chipped and peeling paint on the two walls around the resident’s bed. The Maintenance Director later confirmed that the walls in the room were in need of repair to ensure a homelike environment for Resident 43.
Failure to Provide Ordered Pain Medication
Penalty
Summary
The facility failed to provide pain management for two residents who had physician-ordered Lidocaine 4% patches for chronic pain. Resident 7 was cognitively intact, usually understood and could usually understand others, required staff assistance with daily care needs, and received scheduled pain medication. Her care plan identified chronic back pain, and the physician ordered one Lidocaine 4% patch daily in the morning for back and neck pain. Nursing administration notes documented that the patch was unavailable on multiple mornings, and it was not administered as ordered. Resident 48 was also cognitively intact, understood and could be understood, required assistance with daily care needs, and received scheduled pain medication. Her care plan identified pain in both knees and the right shoulder, and the physician ordered one Lidocaine 4% patch daily in the morning to be applied to the bilateral knees and right shoulder, with staff instructed to cut the patch into three strips. Nursing administration notes showed the patch was unavailable on multiple occasions, and the resident stated the facility had run out of Lidocaine patches multiple times and that she had chronic pain. The DON confirmed the patches were not administered as ordered because the facility ran out, and staff did not notify her or the medical director.
Cold and Unpalatable Meal Service
Penalty
Summary
Food and drink were not served at palatable, attractive, and safe temperatures. During interviews, a group of residents stated that food delivered to resident rooms and dining rooms on their floors was served cold. Resident 48 reported that the food was cold, and Resident 103 stated that the food was often cold and tasted bland. During observation of lunch meal service, a test tray left the kitchen and arrived on the third floor 18 minutes later. The lunch meal consisted of spaghetti and meatballs, vegetable blend, strawberry cake, milk, and juice. When the test tray was checked, the spaghetti and meatballs measured 127.0 F, the vegetable blend measured 124.0 F, the milk measured 44.8 F, and the juice measured 45.8 F. The spaghetti, meatballs, and vegetable blend were cool to taste and not palatable. The Corporate Dietary Manager confirmed that foods should be served to residents at proper and palatable temperatures.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their representatives in advance of the risks and benefits of psychotropic medication use and the treatment alternatives before starting or increasing those medications for three residents reviewed. Facility policy dated January 27, 2026 stated that staff and the physician would review with the resident or representative the risks related to not taking the medication as well as appropriate alternatives. However, the clinical record for a cognitively intact resident with depression and bipolar disorder showed orders for Seroquel 25 mg at bedtime, then 50 mg at bedtime, and later 100 mg at bedtime, with no documented evidence that the resident or representative was informed in advance before the dose increases. A second cognitively intact resident had Cymbalta increased from 30 mg to 60 mg daily, and the nursing note stated the resident's representative was aware, but there was no documented written informed consent for the increase. A third resident with cognitive impairment and diagnoses including non-Alzheimer's dementia had orders for Zyprexa 2.5 mg at bedtime and Seroquel 25 mg twice daily, with no documented evidence that the resident or representative was informed in advance of the risks, benefits, and treatment alternatives before the medications were started. The DON confirmed the lack of documented informed consent or evidence of advance notification for these psychotropic medication changes.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify the resident representative of a change in condition after Resident 29 fell. The facility policy dated January 27, 2026 stated that the resident, attending physician, and resident representative are to be promptly notified of changes in the resident's medical or mental condition and/or status. Resident 29's quarterly MDS dated October 23, 2025 showed that she was cognitively intact and needed staff assistance with daily care needs. A nursing note dated January 31, 2026 documented that the resident slid out of her electric wheelchair and onto the floor, but there was no documented evidence that her daughter was notified after the fall. The resident's electronic health record included a special notification banner stating that her daughter was to be contacted at all times for any change related to the resident. The resident stated on February 3, 2026 that she was upset her daughter was not notified, and the DON confirmed that the daughter was not notified after the fall.
Late Completion of Required MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive admission and annual MDS assessments were completed within the required time frames for four of 32 residents reviewed. The RAI User's Manual stated that an admission MDS assessment must be completed no later than 14 days after admission. Resident 6 was admitted and the admission MDS was completed 2 days after admission, while Resident 43 was admitted and the admission MDS was completed 15 days after admission. In addition, annual MDS assessments for Resident 39 and Resident 97 were completed 16 days after their due dates. The DON confirmed in interview that these comprehensive MDS assessments were not completed in the required time frames.
Failure to Keep Fall-Risk Items Accessible and Use Ordered Leg Rests During Transport
Penalty
Summary
The facility failed to ensure the environment remained as free of accident hazards as possible for two residents. The facility policy on falls, dated January 27, 2026, stated that residents identified as fall risks would have interventions in place to prevent further falls. Resident 88’s quarterly MDS assessment dated January 21, 2026, showed that she was cognitively intact and needed assistance with daily care. Her care plan dated December 14, 2025 identified her as at risk for falls and included keeping personal belongings within reach and providing a reacher tool. On February 5, 2026, Resident 88 was observed sitting in her wheelchair beside her bed coloring on her over-bed table. Her crayons were within reach, but her other coloring books and colored pencils were farther down the bed and not within reach, and her reacher tool was on the other side of the bed on her nightstand. The resident stated she would use the reacher tool if she could reach it. An LPN confirmed the reacher tool was out of reach, and the DON confirmed it should have been within reach. Resident 114’s admission diagnosis included fracture of the femur, difficulty walking, and generalized muscle weakness. On February 3, 2026, the resident was transported in a chair toward the dining room for lunch without leg rests. The nurse aide confirmed the leg rests were not applied because they were in the therapy department, and the DON confirmed leg rests should have been used as ordered during transport.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label and store medications and biologicals in accordance with its policy and accepted professional principles. In the second floor medication cart, surveyors observed one Insulin Lispro subcutaneous solution pen that had expired and one Novolog injection solution pen that had been opened but not dated. The facility policy stated that opened or accessed multi-dose vials are to be dated and discarded within 28 days unless the manufacturer specifies otherwise. An LPN confirmed that the expired Insulin Lispro pen should have been discarded and that the open Novolog pen should have been labeled with the date it was opened. In the third floor medication room, surveyors observed a box of Lorazepam syringes in the refrigerator, but the refrigerator was not locked and the narcotic box was not permanently affixed to the refrigerator. An LPN confirmed that the medication refrigerator was not locked and that the narcotic box was not permanently affixed. The DON also confirmed that the expired insulin pen should have been discarded, the open insulin pen should have been dated, the narcotic refrigerator should have been locked, and the narcotic box should have been permanently affixed to the refrigerator.
QAPI Committee Failed to Sustain Compliance With Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct and maintain compliance with repeated quality deficiencies identified in prior surveys and the current survey. The report states that plans of correction from the annual survey ending January 10, 2025 and the complaint survey ending March 5, 2025 included quality assurance systems and audits to be reviewed by the QAPI committee, but the current survey ending February 5, 2026 found recurring deficiencies in safety/accidents, labeling and storage of medications, palatable food, and sanitary food practices. For safety/accidents, the prior plan of correction stated that audits would be completed and reported to the QAPI committee, but the current survey cited continued noncompliance under F689. For labeling and storage of medications and palatable food, the prior plan of correction also relied on audits and QAPI review, yet the current survey cited ongoing noncompliance under F761. For sanitary food practices, prior plans of correction from both the January 10, 2025 and March 5, 2025 surveys stated that audits would be completed and reported to the QAPI committee, but the current survey cited continued noncompliance under F812.
Failure to Follow Contact Precautions for Resident with C. diff
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident with C. diff. The resident was admitted to the facility and had physician orders dated January 28, 2026, for Vancomycin 125 mg every six hours for 14 days for C. diff, as well as an order for contact precautions. A nursing note dated February 2, 2026, stated that the resident’s chemotherapy treatment was changed from February 4, 2026 to February 18, 2026 due to active C. diff infection. During an observation on February 4, 2026, a nurse aide entered the resident’s room without putting on a gown and gloves and performed perineal care and changed the resident’s adult brief while wearing only gloves. The resident stated she did not attend in-person activities because she had C. diff, and a sign outside her room indicated contact precautions requiring staff to wear gloves and a gown for care needs. The nurse aide confirmed she did not know the resident was on contact precautions and said she should have asked another staff member. The DON later confirmed that the nurse aide should have donned a gown before providing care.
Failure to Complete Required Nurse Aide In-Service Training
Penalty
Summary
The facility failed to ensure that required in-service training was completed for one of four nurse aides reviewed, identified as Nurse Aide 6. Review of her personnel file showed that she was hired on March 28, 2017, and review of her continuing education transcript showed that she did not have the required 12 hours of nurse aide training per year. The Director of Nursing confirmed in interview on February 4, 2026 at 3:33 p.m. that Nurse Aide 6 did not complete the necessary 12 hours of training.
Failure to Maintain Safe Room Temperatures for Cognitively Impaired Residents
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for three residents who were in a day room where the temperature exceeded the facility's policy range. The facility's policy, last reviewed on January 30, 2024, required temperatures to be maintained between 71°F and 81°F. However, on June 26, 2025, the fourth floor day room was observed to have a temperature of 83.9°F. Three residents, all of whom were severely cognitively impaired, dependent on staff for care, and diagnosed with dementia, were present in the room during this time. Observations noted that one resident's face appeared clammy and another's face was flushed and pink after being in the overheated room. Staff interviews revealed that an audit of all PTAC units had been conducted two days prior, identifying multiple non-functioning units, including the one in the affected day room. The Maintenance Director confirmed the malfunction, and the Nursing Home Administrator acknowledged that common areas should be kept within safe temperature ranges. The deficiency was cited under federal and state regulations for failing to provide reasonable accommodation of resident needs and preferences, specifically regarding environmental temperature control.
Plan Of Correction
Plan of Correction: 1. Residents 7, 8, & 9 who were in 4th floor dayroom when temperature was identified above 81 degrees Fahrenheit was redirected to climate-controlled area on unit immediately. 2. New window air conditioner unit was installed to maintain a safe temperature of 71 degrees Fahrenheit to 81 degrees Fahrenheit within the 4th floor dayroom. Corrective actions were put into place to ensure the deficient practice does not reoccur. 3. The administrator re-educated the Maintenance Director on the Facility Policy "Homelike Environment," ensuring that the facility will maintain comfortable temperatures between 71 degrees F and 81 degrees F. 4. A scheduled preventative maintenance program was put into place requiring daily temperature checks to be completed in the 4th floor dayroom for two weeks. After that, audits will be reviewed monthly for the next three months, and then randomly thereafter, with the results of these audits brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Allegation of compliance 7/14/25 I certify this document to be a true and correct statement of deficiencies and approved facility plan of correction for the above-identified facility survey.
Failure to Maintain PTAC Filters in Safe Condition
Penalty
Summary
The facility failed to ensure that essential equipment, specifically Packaged Terminal Air Conditioner (PTAC) units in resident rooms, were maintained in safe operating condition. Observations in two separate resident rooms revealed that the PTAC filters were covered with a thick, gray-brown layer of removable debris. The Maintenance Director confirmed during interviews that the filters needed cleaning and stated his belief that filters should be cleaned approximately every six months. He also reported that since starting employment in January 2025, he had not cleaned any filters as part of routine maintenance and believed the last cleaning occurred in October or November 2024. Manufacturer instructions for the PTAC units require filter cleaning every two weeks or more often if necessary.
Failure to Schedule Dental Appointment for Tooth Extraction
Penalty
Summary
The facility failed to ensure that a dental appointment was scheduled for a resident who required a tooth extraction. According to facility policy, routine and emergency dental care, including follow-up appointments, must be provided. A quarterly MDS assessment indicated that the resident was cognitively intact, required staff supervision, and had her own natural teeth. A physician's order directed that the resident see an oral surgeon for a tooth extraction, but as of the date of review, there was no documented evidence that the appointment had been made or that the procedure had occurred. The resident reported ongoing tooth sensitivity and confirmed that the extraction had not taken place. The DON confirmed that the necessary appointment was never scheduled.
Incomplete and Inaccurate Clinical Record Documentation for Denture Care
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident. A quarterly MDS assessment indicated that the resident was able to communicate and had a diagnosis of diabetes. A dental summary documented the insertion of lower complete dentures and that care instructions were provided. However, during an interview and observation, the resident was found to have no natural teeth and was not wearing dentures, stating that his dentures were broken and unavailable. Review of nurse aide documentation over several months showed inconsistent entries regarding denture care, with some shifts marked as 'not applicable/refused' and others as 'yes.' A nurse aide clarified that she marked 'refused' or 'not applicable' because the resident did not have dentures to care for, not because the resident refused care. The DON confirmed that the documentation was inaccurate, as the resident's dentures were lost, and the records did not reflect the actual situation.
Failure to Follow Care Plan Results in Resident Fall and Fractures
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, resulting in harm. A resident who had recently been admitted following a hip fracture and surgery required extensive assistance from two staff members for bed mobility, as documented in the care plan and Kardex. Despite this, a nurse aide provided care alone and attempted to roll the resident in bed for a complete bed change. During this process, the resident rolled out of bed and fell to the floor, sustaining a nasal bone fracture, an acute nondisplaced fracture of the odontoid process, and a scalp laceration requiring sutures. The nurse aide involved had received education on the facility's abuse and neglect policy, as well as on reviewing the resident's Kardex prior to providing care. However, the aide admitted to not reviewing the Kardex before assisting the resident and was unaware of the requirement for two-person assistance. The Director of Nursing confirmed that the aide's failure to follow the care plan directly resulted in the resident's fall and injuries.
Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Injuries
Penalty
Summary
A deficiency occurred when a resident, who had recently undergone surgery for a hip fracture and required extensive assistance from two staff members for bed mobility, was left under the care of only one nurse aide. The resident's care plan, which specified the need for two staff during bed mobility, was not followed. The nurse aide, without reviewing the resident's Kardex or care plan, attempted to perform a complete bed change alone. During this process, the resident rolled out of bed and fell to the floor. As a result of the fall, the resident sustained multiple injuries, including a nasal bone fracture, an acute nondisplaced fracture through the base of the odontoid process, and a left frontal scalp laceration requiring sutures. The nurse aide later admitted to not reviewing the care plan prior to providing care and was unaware of the two-person assistance requirement. The Director of Nursing confirmed that the failure to follow the resident's care plan for bed mobility led to the resident's fall and subsequent injuries.
Failure to Store Food Safely and Maintain Refrigerator Temperatures
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in three resident refrigerators. Policy required all foods stored in refrigerators or freezers to be labeled with the resident's name and use-by dates, and to be kept at or below 41°F. Observations revealed multiple food items, such as fried chicken, barbequed ham, salad, pizza, and a cheesesteak sandwich, were stored past their labeled use-by dates, with some items remaining in the refrigerators for over a week. Additionally, facility-prepared soup was found with dates exceeding the three-day limit. Staff interviews confirmed that these foods should have been discarded within three days, as per policy. Temperature logs for the refrigerators were not maintained as required, with no documentation since the morning of March 3, 2025. Observed refrigerator temperatures ranged from 48°F to 50°F, exceeding the maximum allowed by policy. Staff interviews confirmed that the dietary department was responsible for cleaning out the refrigerators and recording temperatures twice daily, but these tasks were not completed. Notices on the refrigerators reiterated the policy, but compliance was not observed. The Dietary Director acknowledged the deficiencies in food storage, temperature control, and documentation.
Deficiency in Kitchen Fire Suppression System Maintenance
Penalty
Summary
The facility failed to maintain its cooking facilities in compliance with NFPA 101 standards, specifically regarding the kitchen fire suppression system. During an observation and document review on January 14, 2025, it was found that the facility did not have documentation for the required semi-annual testing and maintenance of the kitchen fire suppression system, which was due between January and June 2024. This deficiency was confirmed during an interview with the Director of Nursing and the Maintenance Director on the same day, affecting one of the nine smoke compartments in the facility.
Plan Of Correction
1. The facility will obtain documentation for the semi-annual testing/maintenance of the kitchen fire suppression system. 2. Maintenance director or designee will verify that semi-annual testing/maintenance of the kitchen fire suppression is completed and audited semi-annually. 3. Nursing home administrator or designee will re-educate the maintenance director of completing semi-annual testing/maintenance of the kitchen fire suppression timely. 4. Maintenance director or designee will audit that semi-annual testing/maintenance of the kitchen fire suppression is completed and audited semi-annually. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed. Date of Compliance will be 2/18/2025.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in one location, specifically affecting one of nine smoke compartments. During an observation on January 14, 2025, at 11:45 a.m., two sprinkler heads located above the dryers in the Laundry Room were found to be dirty and dusty. The accumulation of dirt and dust on these sprinkler heads could potentially affect their activation in the event of a fire. This deficiency was confirmed during an interview with the Director of Nursing and the Maintenance Director on the same day at 2:30 p.m. The failure to maintain the cleanliness of the sprinkler heads indicates a lapse in the regular inspection and maintenance protocols as required by NFPA 25, which governs the inspection, testing, and maintenance of water-based fire protection systems.
Plan Of Correction
1. Sprinkler heads identified have been cleaned. 2. Maintenance director or designee will conduct a facility audit to verify that sprinkler heads are free from dust. 3. Nursing home administrator or designee will re-educate the maintenance director on properly maintaining the sprinkler heads in the facility verifying they are free from dust. 4. Maintenance director or designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify that the sprinkler heads are free from dust. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed. Date of compliance will be 2/18/2025.
Deficiency in Emergency Preparedness Plan
Penalty
Summary
Cedarwood Rehabilitation and Healthcare Center was found to have deficiencies in its Emergency Preparedness (EP) Plan during a survey conducted on January 14, 2025. The facility failed to include updated and accurate names and contact information for its staff and resident physicians, which is a requirement under 42 CFR 483.73. This deficiency was identified through a review of the facility's EP Plan and confirmed during interviews with the Director of Nursing and the Maintenance Director. The survey revealed that the EP Plan did not meet the necessary standards as it lacked essential contact details, which are crucial for effective communication during emergencies. The absence of this information was confirmed by the facility's leadership, indicating a lapse in maintaining the required documentation for emergency preparedness. This oversight has the potential for minimal harm, as it could impede timely communication and coordination in emergency situations.
Plan Of Correction
1. The facility EP plan has been updated to accurately reflect the proper staff and physician contact information. 2. Maintenance director or designee will verify it is updated if information changes. 3. Nursing home administrator or designee will re-educate the maintenance director on accurately and timely updating the EP plan as contact information changes. 4. Maintenance director or designee will audit the EP plan monthly for the next three months to verify contact information is accurate. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed. Date of compliance will be 2/18/2025.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration for one resident. Resident 99, who is cognitively intact and requires assistance for daily care needs, has a diagnosis of renal failure necessitating dialysis. The physician's orders from the dialysis center specified that the resident should receive 210 mg of Auryxia five times a day with meals and snacks. However, a review of the Medication Administration Record for January 2025 revealed that the resident was only receiving the medication three times per day. This discrepancy was confirmed in an interview with the Director of Nursing, who acknowledged that the resident was not receiving the medication as prescribed.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure that physician's orders for enteral feedings were followed for three residents. Resident 16, who was cognitively intact and required maximum assistance, had an order to receive Jevity 1.5 at a rate of 60 ml/hour. However, there was no documentation in the Medication Administration Record (MAR) for January 2025 indicating the amount administered each shift. An LPN admitted to not knowing how to clear the machine to ensure the correct amount was given. The Director of Nursing confirmed the lack of documentation. Resident 54, who was severely cognitively impaired, had orders to check gastric residual volume (GRV) before medication and feeding. An LPN failed to properly verify the GRV by not using the plunger to withdraw stomach contents. Additionally, there was no documented evidence of a reweigh to confirm an 11.4-pound weight loss or weekly weights as recommended. Resident 67, who was cognitively impaired, had orders to check residual volume before each feeding and medication administration, but it was only documented as verified every shift. The Director of Nursing confirmed these deficiencies.
Failure to Serve Palatable Food
Penalty
Summary
The facility failed to serve food that was palatable, as evidenced by observations and resident interviews. A review of the facility's policy on food preparation and service, dated January 25, 2024, indicated that hot foods should be served above 130 degrees Fahrenheit. However, during an interview with a group of residents, it was revealed that food delivered to their rooms was served cold. Observations during the lunch meal service showed that a test tray, which included ground sausage and noodles, broccoli, a rootbeer float dessert cup, milk, and coffee, was served to residents. The test tray's temperature readings showed that the ground sausage and noodles and broccoli were at 120 degrees Fahrenheit, below the required temperature, making them cool and unappetizing. The Dietary Manager confirmed that foods should be served at proper and palatable temperatures.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage and preparation. Observations in the kitchen revealed a box of frozen egg patties that were open to air, which was confirmed by the Dietary Manager. Additionally, the resident refrigerator on the second floor contained multiple opened and undated containers of milk and iced tea, some of which were not labeled with a resident's name and had expired sell-by dates. Interviews with a Registered Nurse and the Dietary Manager confirmed that these items should have been labeled, dated, and discarded after expiration. Further deficiencies were noted in the dishwashing process. The dishwasher was not reaching the required hot water final rinse temperature of 180 degrees Fahrenheit because the hot water booster was not turned on. Dietary Aide 11, who was handling dirty dishes, moved to the clean side and began stacking clean dishes without washing his hands, which was against expected hygiene practices. The Dietary Manager confirmed that the dishwasher could use chemicals if necessary, but the hot water booster should have been on to ensure proper sanitization. The Director of Nursing also confirmed that dietary staff were expected to wash their hands between handling dirty and clean tasks.
Neglect in Resident Transfer Procedure
Penalty
Summary
The facility failed to ensure that residents were free from neglect, as evidenced by the incident involving Resident 95. The resident, who was cognitively intact and required maximum assistance for transfers due to conditions including arthritis and a recent total knee arthroplasty, was transferred improperly by a nurse aide. The resident's care plan specified a two-person physical assist for transfers, but Nurse Aide 1 transferred the resident alone, resulting in pain to the resident's right shoulder. This incident was reported by the resident to the physical therapy department, which then initiated an investigation. The investigation revealed that Nurse Aide 1 did not verify the transfer status before proceeding with the transfer, which was against the facility's policy on abuse, neglect, exploitation, and misappropriation. Despite having been educated on following care plans, Nurse Aide 1 failed to adhere to the required protocol, leading to the resident's injury. The Director of Nursing confirmed the resident's transfer requirements and the nurse aide's failure to comply, which resulted in the resident experiencing pain.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to the resident, responsible party, and Ombudsman regarding the reason for hospitalization for two residents. Resident 19, who was cognitively intact and required assistance for daily care needs, was sent to the hospital for evaluation after lab results were reviewed by a certified registered nurse practitioner. Although the resident's responsible party was notified and agreed to the transfer, there was no documented evidence of a written notice being provided to the responsible party or the Ombudsman. Similarly, Resident 67, who was cognitively impaired and dependent on staff for daily care needs, was transferred to the hospital after being found diaphoretic and hard to arouse. The family requested the transfer, and the physician agreed. However, there was no documented evidence that a written notice of the transfer was provided to the resident's responsible party or the Ombudsman. The Director of Nursing confirmed that the facility did not provide the required written notices for both residents.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify appropriate parties about the bed-hold policy during hospital transfers for two residents. The facility's policy, dated January 25, 2024, mandates that residents and/or their representatives be informed in writing of the bed-hold policy. However, for Resident 19, who was cognitively intact and required staff assistance for daily care, there was no documented evidence of such notification when the resident was transferred to the hospital on June 6, 2024, following a CRNP's order for evaluation. Similarly, Resident 67, who was cognitively impaired and dependent on staff, was transferred to the hospital on September 24, 2024, after being found diaphoretic and hard to arouse. The family requested the transfer, and the physician agreed. Again, there was no documented evidence that the resident or their responsible party was informed of the bed-hold policy. The Director of Nursing confirmed the lack of documentation for both residents, acknowledging that notifications should have been issued.
Failure to Develop Individualized Care Plan for Anti-Coagulant Use
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident regarding the use of an anti-coagulant medication. A quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and was prescribed Eliquis, an anti-coagulant, to be taken every 12 hours. Despite the medication being administered as per the physician's orders, there was no documented evidence of a care plan addressing the specific use of the anti-coagulant for this resident. An interview with the Director of Nursing confirmed the absence of an individualized care plan for the resident's anti-coagulant use, acknowledging that it should have been included.
Failure to Update Care Plan for Discontinued PICC Line
Penalty
Summary
The facility failed to update the care plan for Resident 91 to reflect changes in care needs. A quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact, required substantial assistance, and was receiving an intravenous antibiotic through a peripherally inserted central catheter (PICC) in her right upper arm. However, physician's orders dated December 10, 2024, instructed for the PICC line to be removed, and observations on January 7, 2025, confirmed that the PICC line was no longer present. Despite this, the care plan was not updated to reflect the discontinuation of the PICC line, as confirmed by the Director of Nursing during an interview on January 10, 2025.
Failure to Clarify Physician's Order Leads to Medication Error
Penalty
Summary
The facility failed to clarify a physician's order for a resident, leading to a medication administration error. The resident, who was cognitively impaired but able to understand and be understood, had a physician's order dated January 8, 2024, for Lexapro, a medication used to treat depression and anxiety disorders. The order was confusing as it stated to administer 10 mg of Lexapro but also instructed to give two tablets for a total of 15 mg. This discrepancy was not clarified by the nursing staff. As a result, the resident received 15 mg of Lexapro on January 8 and 9, 2024, as documented in the Medication Administration Record. An LPN observed administering one and one-half tablets of Lexapro, which was consistent with the pharmacy's supply of 10 mg tablets. The LPN acknowledged the confusion in the order and the need for clarification. The Director of Nursing confirmed that the order should have been clarified to prevent the administration error.
Failure to Ensure Adequate Supervision and Assistance During Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for two residents. For Resident 79, who was cognitively intact and required extensive assistance with transfers, the staff did not engage the brakes on the mechanical lift during a transfer from a wheelchair to a bed. This was against the facility's policy and the manufacturer's instructions for the lift, which required brakes to be engaged during lifting and lowering. Both Nurse Aide 3 and Nurse Aide 4 confirmed the oversight, and the Assistant Director of Nursing acknowledged that the brakes should have been engaged. For Resident 95, who was also cognitively intact and required maximum assistance for transfers, a nursing note indicated new shoulder pain after a transfer. An investigation revealed that Nurse Aide 1 transferred the resident alone, contrary to the care plan that required a two-person assist. The resident reported that the aide twisted her arm during the transfer, causing pain. The Director of Nursing confirmed that the transfer was conducted improperly, and documentation showed that Nurse Aide 1 had previously been educated on following care plans.
Failure to Discard Expired Insulin Pens
Penalty
Summary
The facility failed to properly discard expired insulin pens in two of the three medication carts reviewed, specifically on the second and third floor long hall medication carts. According to the facility's policy and the manufacturer's instructions, insulin pens should be discarded 28 days after being opened. However, during observations, it was found that a Lantus insulin pen for Resident 17, which was opened on a previous date, was still in the cart beyond the 28-day period. This was confirmed by an LPN during the observation. Similarly, a Lispro insulin pen for Resident 89 was also found in the second-floor medication cart past the 28-day expiration period. The pen was opened on a previous date and should have been discarded, as confirmed by an RN during the observation. The Director of Nursing also confirmed that insulin pens should be discarded 28 days after being opened and in use, indicating a lapse in adherence to the facility's medication management policies.
Failure to Follow Planned Menu
Penalty
Summary
The facility failed to adhere to their planned menu, as evidenced by a review of facility policies, written menus, and observations, as well as interviews with staff and residents. The facility's policy, dated January 24, 2024, required that menus be written in advance, posted in resident areas, and any deviations recorded on a substitution log. However, during an interview with a group of residents on January 7, 2025, it was revealed that they do not always receive the meals listed on the menu. Specifically, the lunch menu for January 7, 2025, indicated that residents were to receive a lemon brownie, but observations in the kitchen showed a yellow cake prepared instead. During the lunch meal service, a blonde brownie was served instead of the lemon brownie. The Dietary Manager confirmed on January 9, 2025, that the substitution occurred because there was no recipe available for the lemon brownie.
Repeated Deficiencies in Care Plans and Food Service
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated citations in multiple surveys. These deficiencies included issues with creating and updating comprehensive care plans, maintaining quality of care, meeting professional standards, and ensuring a safe environment free of accident hazards. Despite developing plans of correction that involved completing audits and reporting results to the QAPI committee, the facility did not achieve ongoing compliance with these regulations. Additionally, the facility was cited for deficiencies related to food service, including not following menus made in advance, failing to provide nutritious and palatable food, and not preparing, storing, and serving food under sanitary conditions. These issues were identified in surveys conducted throughout 2024 and into early 2025, indicating a persistent failure by the QAPI committee to implement effective corrective actions and maintain compliance with the required standards.
Temperature Control Issues in Dining Room
Penalty
Summary
The facility failed to maintain comfortable temperatures in one of its dining rooms, specifically the fourth floor dining room. On January 7, 2025, observations revealed that the temperature was 64 degrees Fahrenheit while five residents were waiting for lunch. Further observations on January 9, 2025, showed temperatures ranging from 60 to 70 degrees Fahrenheit while five people were eating. Interviews with the Maintenance Director indicated that the dining room doors were closed, preventing heat from circulating from the hallways, and that the temperature was outside acceptable parameters. The HVAC company owner noted that dampers were slightly open to the outside, allowing cold air to circulate into the dining room, but once closed, the temperatures returned to normal range.
Failure to Notify Resident's Family of New Physician's Order
Penalty
Summary
The facility failed to notify a resident's representative about a new physician's order, which is a requirement according to the facility's policy on changes in a resident's condition or status. The policy mandates that a nurse must inform the resident's representative of any significant change in the resident's physical, mental, or psychosocial status. In this case, a resident who was cognitively impaired and diagnosed with dementia had a new order for a bladder/renal ultrasound due to sediment in the urine, as noted by the family and reported by the resident. However, there was no documented evidence that the resident's family was informed of this new order. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation regarding the notification to the resident's family. The family had expressed their desire to be informed about the ultrasound results, indicating that they were not aware of the new order. This oversight was identified during a review of facility policies, clinical records, and staff interviews, highlighting a failure in communication and adherence to the facility's notification policy.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, identified as Resident 6, who was cognitively intact and had diagnoses including coronary artery disease, heart failure, and asthma. During an observation, it was noted that a stand-up fan, belonging to the facility, was blowing directly on the resident while having a significant amount of visible dirt and debris accumulated on its blade cover. This condition was confirmed by both the Housekeeping Aide and the Infection Preventionist, who acknowledged that the fan should have been clean but was not. Further interviews with the Housekeeping Manager and the Director of Nursing confirmed that the fan cover should have been cleaned with a damp rag during room cleaning, but it was not. The deficiency was identified under the resident's rights to a safe, clean, comfortable, and homelike environment, as outlined in the facility's policy on cleaning and disinfecting. The failure to maintain cleanliness was a violation of the resident's rights and the administrator's responsibility as per the relevant Pennsylvania Code.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to maintain or improve their abilities to perform activities of daily living (ADLs) and ambulate. The resident, who was cognitively impaired and had multiple diagnoses including pulmonary fibrosis, respiratory failure, asthma, and rheumatoid arthritis, experienced a decline in functional mobility. Initially, the resident was able to perform bed mobility tasks and functional transfers with minimal assistance and could ambulate 60 feet with a walker. However, after being discharged from physical therapy, no program was implemented to maintain the resident's functional mobility. Subsequent therapy sessions revealed a further decline in the resident's abilities, requiring moderate to maximum assistance for tasks previously performed with less help. Despite recommendations for a restorative nursing program to maintain the resident's current level of performance and prevent further decline, there was no documented evidence that such a program was developed or implemented. Interviews with facility staff, including the Director of Nursing, confirmed the absence of restorative nursing programs to prevent decline and maintain the resident's ability to perform ADLs and ambulation.
Failure to Follow Transfer Protocols Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that safe transfer techniques were used in accordance with the care plan for a resident, resulting in a fall. The resident, who was cognitively intact and had a diagnosis of a fracture, anxiety, and depression, was supposed to be transferred using a stand-up lift with a medium sling and the assistance of two staff members. However, during a transfer from a chair to a bed, the resident lost balance and was lowered to the floor by a nurse aide onto her left knee, although no injuries were reported. The incident occurred because the nurse aide did not follow the resident's care plan. The aide reported that he transferred the resident without the sit-to-stand lift, as he was under the impression that it was unsafe based on a previous comment by an LPN. The aide did not verify the care plan before proceeding with the transfer. The Director of Nursing confirmed that the care plan was not followed, which led to the deficiency being cited as past non-compliance.
Failure to Monitor Resident's Weight as Recommended
Penalty
Summary
The facility failed to ensure that weekly weights were obtained for a resident who experienced significant weight loss, as recommended by the dietician. The resident, who was cognitively impaired and required substantial assistance with care needs, had a diagnosis of protein calorie malnutrition and had been experiencing significant weight loss. The dietician had noted the resident's weight loss and recommended weekly weight monitoring to assess the need for further nutritional interventions. However, there was no documented evidence that these weekly weights were obtained or that the dietician continued to monitor the resident's weight loss and nutritional status. The Director of Nursing confirmed that the dietician did not place physician's orders for the weekly weights, resulting in the failure to monitor the resident's weight as recommended. This oversight was identified during a review of the resident's clinical records for October and November, which showed no documentation of the recommended weekly weights. The deficiency was cited under 28 Pa. Code 211.12(d)(3)(5) Nursing Services, indicating a lapse in the facility's responsibility to provide adequate nursing services to maintain the resident's health.
Failure to Obtain Ordered Laboratory Specimens
Penalty
Summary
The facility failed to ensure that laboratory specimens were obtained as ordered for a resident. The resident, who was cognitively impaired and required substantial assistance with care needs, had significant weight loss and multiple diagnoses, including pulmonary fibrosis, respiratory failure, asthma, rheumatoid arthritis, and protein calorie malnutrition. A physician's order dated October 7, 2024, required bloodwork to be completed on the same day, including tests for calcium level, sed rate, CHEM 4, albumin, AST, ALT, Creatinine, and a CBC with auto diff. Despite the physician's order, the resident refused the annual labs on October 8, 2024, and staff planned to attempt again on October 9, 2024. The medical director and resident representative were informed of the refusal. On October 9, 2024, the resident again refused the labs, and staff planned another attempt on October 10, 2024. However, there was no documented evidence that the bloodwork was attempted or obtained on October 10, 2024. The Director of Nursing confirmed the lack of documentation for the ordered bloodwork.
Failure to Follow Planned Menu and Notify Residents of Changes
Penalty
Summary
The facility failed to adhere to its planned menu as required by its policy, which mandates that menus be served as written unless changes are made due to preference, unavailability, or special meals, with deviations recorded. On December 10, 2024, the lunch menu was supposed to include chunky cheeseburger casserole, glazed sweet carrots, garlic bread, and lemon brownies. However, observations revealed that a resident received a meal with a half of a hot dog bun with butter instead of garlic bread, and a chocolate brownie instead of a lemon brownie. The resident expressed that the menu often does not match what is served and had documented the discrepancies on her menu. The Dietary Manager confirmed that residents were not informed of the menu changes and acknowledged that the advertised items, garlic bread and lemon brownies, were not provided. The manager, who is new to the facility but experienced in dietary services, stated that she is working on improving the dietary experience. This failure to follow the planned menu and notify residents of changes is a violation of the facility's dietary services policy.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to serve food in accordance with professional standards for food safety by not ensuring that food was served at appropriate temperatures. During a test tray observation conducted on December 10, 2024, it was noted that the food cart left the kitchen at 12:49 p.m. and arrived on the second floor at 12:50 p.m. The last resident tray was delivered, and the test tray was tested at 1:02 p.m. The test tray included chunky cheeseburger casserole, glazed sweet carrots, bread, brownies, milk, pink lemonade, and coffee. The temperatures recorded were 129.7 degrees Fahrenheit for the casserole, 116.1 degrees Fahrenheit for the carrots, 140 degrees Fahrenheit for the coffee, 49.1 degrees Fahrenheit for the milk, and 60 degrees Fahrenheit for the pink lemonade. These temperatures did not meet the facility's policy standards, which require hot foods to be at least 135 degrees Fahrenheit and cold foods to be at 41 degrees Fahrenheit or lower. The Dietary Manager confirmed during an interview that the food should have been served at safe and appropriate temperatures in compliance with safe food handling practices. The manager acknowledged that the facility currently lacks hot plates to maintain food warmth and expressed a future plan to serve meals from steamers in the dining areas to ensure hot food for residents. The deficiency was identified under 28 Pa. Code 211.6(f) Dietary Services, indicating a failure to adhere to the established guidelines for food safety and temperature control.
Failure to Ensure Dietary Staff Wore Appropriate Hair Coverings
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that dietary staff wore appropriate hair coverings. The facility's policy, dated January 25, 2024, mandates that all kitchen employees must wear hair restraints to effectively keep hair properly restrained. However, during observations on December 10, 2024, it was noted that the Dietary Manager was involved in stirring, temping, and plating food with two to three inches of hair at the back of her head and approximately one inch of hair on the side of her face not covered. Additionally, a dietary worker was observed placing desserts and lids onto meal trays with sideburns that were not completely covered. An interview with the Dietary Manager confirmed that both she and the dietary worker should have had their hair completely covered when handling food for residents, which they did not.
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 165 citations issued within 25 miles in the last 12 months — 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 Tyrone
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maybrook Hills Rehabilitation And Healthcare Cente | 12.9 mi | ★★★★★ | 3 | 0 |
| Midtown Oaks Health & Rehab Center | 13.4 mi | ★★★★★ | 24 | 0 |
| Hilltop Healthcare And Rehabilitation Center | 15.1 mi | ★★★★★ | 14 | 0 |
| Westminster Woods At Huntingdo | 16.1 mi | ★★★★★ | 7 | 0 |
| Heritage Ridge Senior Living At Windy Hill | 16.3 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.