Cedar Health and Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 26, 2025

  Based on observation, interview, and record review, it was determined for 5 out of 41 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, 5 residents had multiple falls without continued attempts at interventions to prevent additional falls. Additionally, one resident had repeated accidents while operating his motorized wheelchair and had been assessed as not safe to operate the motorized wheelchair. Resident identifiers: 1, 39, 43, 53, and 62.Findings included:1. […]

• No harm, potential for more than minimal, patternF656Jun 26, 2025

  Based on observation, interview and record review, for 6 of 41 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified. Specifically, after residents sustained falls there were no interventions or the interventions were reused and a resident did not have hospice services care planned. Resident identifiers: 1, 39, 43, 53, 62 and 64.Findings include: 1. Resident 53 was admitted to the facility on [DATE] with diagnoses which included palliative care, anxiety disorder, and Alzheimer's disease. On 6/23/25 at 8:01 AM, an observation was made of resident 53. […]

• No harm, potential for more than minimal, patternF804Jun 26, 2025

  Based on observation, interview and record review, for 5 of 41 residents, the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, residents complained of cold food and too much processed food. Resident Identifiers: 6, 9, 15, 33, and 75.Findings Included:On 6/22/25 at 2:17 PM, an interview was conducted with resident 33 who stated he had received a cold hamburger with beef that tasted like fake meat. Resident 33 stated it tasted like it had been mixed with something. Resident 33 stated he had provided feedback to the kitchen staff, but it did not seem to help. Resident 33 stated he would eat lunch, but would not eat breakfast or dinner. […]

• No harm, potential for more than minimal, patternF812Jun 26, 2025

  Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and the walk-in refrigerator were open to the air.Findings included:On 6/22/25 at 1:03 PM, an initial walk-through was conducted in the kitchen. In the walk-in freezer, a package of diced chicken was open to air and a box of ground beef patties were open to air.On 6/25/25 at 1:31 PM, a second walk-through was conducted in the kitchen. In the walk-in refrigerator, a box of raw bacon with a written date of 6/16/25 was open to air. [Note: The box stated store at 0 degrees, keep frozen or below.]On 6/25/25 at 2:06 PM, an interview was conducted with the Dietary Manager (DM). […]

• No harm, potential for more than minimal, patternF609Jul 13, 2023

  Based on record review and interview it was determined for 6 of 20 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). Specifically, entity reports of multiple abuse allegations were not submitted to the SSA in a timely manner. Resident identifiers: 9, 25, 43, 46, 124 and 225. Findings include: 1. […]