Cedar Healthcare Center

In the surveyor’s words

From the most serious findings on record at Cedar Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761May 7, 2021

  Based on observation, interview, medical record review and policy review, it was determined that the facility failed to ensure proper storage of expired medications and medication needing refrigeration for 1 out 1 medication room observed and 3 out of 3 medication carts observed. (Resident identifiers are #36, #38, #53 and #61.) Findings include: Nubble unit medication room Observation on 5/5/21 at 8:13 a.m. with Staff C (Licensed Practical Nurse (LPN)) at the nubble unit medication room refrigerator revealed an used [MEDICATION(S)] vial with a labeled date of 1/19/21 on the container. Further observation revealed that the storage instruction on the container indicated that entered vials are to be discarded after 30 days. […]

• No harm, potential for more than minimal, isolatedF756Jun 26, 2025

  Based on interview and record review, it was determined that the facility failed to ensure that the facility acted upon provider approved recommendations that were identified by the pharmacist during the monthly Pharmacy Medication Regimen Review for 1 of 5 residents reviewed for unnecessary medications in a final sample of 18 residents. (Resident Identifier is #61). Findings include: Review on 6/25/25 of Resident #61's Pharmacy Review dated 3/13/25 revealed a recommendation to the physician/prescriber to Please consider ordering a serum Vitamin D 25-OH level (25-hydroxyvitamin D). Further review revealed that Yes, order a serum Vitamin D 25-OH level was checked in the affirmative and signed/dated by Staff A (Advanced Practice Registered Nurse) on 3/19/25. […]

• No harm, potential for more than minimal, isolatedF926May 8, 2024

  Based on record review and interview, it was determined that the facility failed to implement smoking policies for 1 of 2 residents reviewed for smoking in a final sample of 22 residents (Resident Identifier #66). Findings include: Review on 5/7/24 of the facility's list of residents who smoke revealed that Resident #66 was identified as a smoker by the facility. Review on 5/7/24 of Resident #66's medical record revealed that Resident #66 was admitted to the facility on [DATE]. Review on 5/7/24 of Resident #66's medical record revealed Resident #66 did not have a smoking assessment to assess for safety of smoking. […]

• No harm, potential for more than minimal, isolatedF689May 12, 2023

  Based on observation, interview, and record review it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for 1 of 2 residents reviewed for smoking in a final sample of 27 residents (Resident Identifier is #3). Findings include: Review on 5/12/23 of Resident #3's care plan revealed that Resident #3 smokes independently, and has the following interventions in place: 1. Educate and remind to keep smoking materials in a safe place. 3. Educate and remind of center policy and expectations. 4. Re-enforce that no smoking is allowed in the building. Review on 5/12/23 of Resident #3's smoking assessment dated [DATE] revealed that Resident #3 was assessed to smoke independently and is aware of the facility's smoking policy. […]

• No harm, potential for more than minimal, isolatedF761May 12, 2023

  Based on observation, interview, and policy review, it was determined that the facility failed to ensure eye medications were labeled with open expiration dates and that expired medications were removed from use on 1 of 3 medication carts and 1 of 2 medication rooms observed (Resident Identifier is #44). Findings include: Observation on 5/10/23 at 8:45 a.m. of the Bay Unit medication room with Staff E (Licensed Practical Nurse) revealed 6 packets of Hydrocortisone 1 percent (%) cream with an expiration date of 11/2022 available for use on Bay Unit. Interview on 5/10/23 at 8:45 a.m. with Staff E confirmed the above finding. 46654 Observation on 5/10/23 at approximately 9:27 a.m. […]