Cedar Hollow Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Dec 30, 2025

  Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of four residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was implemented when CNA B attempted to transfer the resident himself, instead of using a mechanical lift, which resulted in a fall. Resident #1 was hospitalized and required surgery for a fracture of the left femur.The non-compliance was identified as PNC. […]

• Immediate jeopardy, isolatedF689Dec 30, 2025

  Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #1) reviewed for accidents and hazards.The facility failed to ensure Resident #1 was properly transferred from her bed to her wheelchair. CNA B attempted to transfer the resident by himself, instead of using a mechanical lift, which resulted in a fall. Resident #1 was hospitalized and required surgery for a fracture of the left femur.The non-compliance was identified as PNC. The noncompliance began on 11/30/2025 and ended 12/01/2025. The facility had corrected the non-compliance before the survey began.This failure could place the residents at risk of accident, injury or serious harm. […]

• Immediate jeopardy, isolatedF600May 10, 2024

  Based on interviews and record review, the facility failed to ensure each resident had the right to be free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed to ensure a safe environment free from abuse for Resident #1 when CNA A entered his room and cut and stabbed him multiple times which caused him to sustained stab wounds to his right neck, left chest, and left arm on [DATE]. The noncompliance was identified as PNC. The IJ was from [DATE] to [DATE]. The facility had corrected the noncompliance before the survey began. This failure caused serious injury resulting in hospitalization and placed the resident at risk of death. […]

• Actual harm, isolatedF686Aug 20, 2026

  Based on interviews and record reviews, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 of 3 residents (Resident #1) reviewed for pressure ulcers.The facility failed to ensure preventative measures were in place to prevent Resident #1 from developing a DTI to his right hip, right foot, and right heel within 2 days of his admission to the facility.This failure placed residents at risk of the development and/or deterioration of pressure ulcers. […]

• Actual harm, isolatedF689Aug 7, 2026

  Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents. The facility failed to provide Resident #1 with adequate supervision while transferring the resident from a shower to his bed on 06/25/26, which resulted in the resident sustaining a laceration to his leg that required treatment at the hospital. The noncompliance was identified as past noncompliance (PNC). The PNC began on 06/25/26 and ended on 06/26/26. The facility had corrected the noncompliance before the state's survey began. […]