Cedar Crest Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Cedar Crest Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF804Aug 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure drinks were served at a safe and appetizing temperature when cold drinks were served with a temperature higher than 41F (Fahrenheit, unit of measurement).This failure had the potential to discourage residents from increasing the amount they eat and drink.Resident census was 80.Findings:During the kitchen tray line observation on 8/7/25 at 12:03 p.m. with the Dietary Supervisor (DS), temperature of cold drinks being served were checked. Milk was 56.7 F and yogurt was 55.8 F. These drinks were kept in a black bin on a movable shelf and kitchen staff took one from the bin during tray line. DS stated cold drinks must be at temperature below 41 F. […]

• No harm, potential for more than minimal, patternF812Aug 11, 2025

  Based on observation, interview and record review, the facility failed to ensure proper sanitation and maintenance of the ice bin (where ice is stored) when it was found to have black substances in the ice chute (ice dispenser), green substances on the corner edges, fine grayish particles on the exterior front, and was not cleaned according to the manufacturer's manual.Due to these systemic failures (as stated above) with potential to affect all residents and staff who uses and consumes ice from the ice bin, the facility needed to take immediate action to correct the noncompliance.On 8/6/25 at 7:30 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm,… […]

• No harm, potential for more than minimal, patternF880Aug 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. The filter of Resident 6's oxygen concentrator was dusty;2. Licensed vocational nurse M (LVN M) did not cleanse her hands before administering Pataday eye drops (allergy itch relief eye drops) to Resident 12;3. Licensed vocational nurse N (LVN N) did not cleanse her hands and change gloves before administering Fluticasone nasal spray (used to relieve allergy symptoms in the nose) to Resident 95; and4. Unlabeled personal care items in a shared bathroom by multiple residents.Findings: 1. […]

• No harm, potential for more than minimal, patternF908Aug 11, 2025

  Based on observation, interview and record review, the facility failed to maintain equipment in safe operating and sanitary conditions when:A bedside commode (a portable toilet, chair like structure to accommodate different user heights)'s metal pipe was found with dark brown patches and paint peeling off;Sink overflow drain hole area was found with black, white and dark brown spots in room C's bathroom;Lint filter and lint compartment with lint for dryer 1 and 2.The above failures had the potential to adversely affect the health and safety of residents in the facility.Findings:1) During an observation on 8/5/2025 at 10:06 a.m., noted bed side commode placed on a toilet commode in a resident (room D)'s bathroom with dark brown patches and paint peeling off on metal pipe below and behind… […]

• No harm, potential for more than minimal, patternF656Mar 29, 2024

  Based on observation, interview, and record review, the facility failed to develop and implement comprehensive, resident-centered care plans for six out of twenty-two sampled residents (Residents 37, 1, 53, 71, 41, and 2), when the activity care plans of Residents 37, 1, 53, 71, 41, and 2 were not comprehensive and resident-centered. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. […]