Cedar Lake Health and Rehab Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Feb 19, 2025

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 59 residents residing in the facility. The dry storage area, coolers, and freezer contained multiple open, undated, unlabeled, and/or expired items. Documentation logs for the parts per million (PPM) of the sanitizing solution in the sanitizing buckets and 3-compartment sink were not completed. Staff did not appropriately test and maintain dishwasher temperatures. Staff did not maintain a sanitary dishwashing practice. Findings include: On [DATE], Director of Culinary Operations (DCO)-I verified the facility follows the Food and Drug Administration (FDA) Food Code as their standard of practice. […]

• No harm, potential for more than minimal, widespreadF812Dec 6, 2023

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 50 residents residing in the facility. The facility did not monitor and document food cooling temperatures. The facility did not monitor and document dishwasher surface temperatures. There were multiple open, undated, and/or expired food items in the dry storage area, and three coolers. Findings include: On [DATE] Dietary Manager (DM)-D verified the facility follows the Food and Drug Administration (FDA) Food Code 2022 as the facility's standard of practice. […]

• No harm, potential for more than minimal, patternF657Apr 21, 2026

  Based on staff interview and record review, the facility did not review and revise the comprehensive plan of care for 5 residents (R) (R73, R61, R56, R21, and R68) of 8 sampled residents.R73 fell on 4/4/26. An intervention for a Posey grip on top of R73's wheelchair cushion was not added to R73's care plan.R61 fell on 4/13/26. A post-fall intervention was not added to R61's care plan.R56 had a specialty air mattress that was not reflected on R56's care plan or Kardex (an abbreviated care plan used by nursing staff) and staff did not check the functioning of the air mattress each shift. […]

• No harm, potential for more than minimal, patternF610Sep 29, 2025

  Based on staff and resident interview and record review, the facility did not ensure allegations of abuse/neglect were thoroughly investigated for 4 residents (R) (R1, R2, R8, and R6) of 8 sampled residents. R1 reported an allegation of abuse involving Certified Nursing Assistant (CNA)-C. During the investigation, staff reported an allegation of abuse involving CNA-C and R2. The facility did not thorougly investigate the allegations of abuse.The facility's grievance file contained grievances from R8 and R6 that included allegations of abuse/neglect involving CNA-E. […]

• No harm, potential for more than minimal, isolatedF609Jun 24, 2026

  Based on interview and record review, the facility did not ensure allegations of abuse/neglect were reported to the State Agency (SA) for 1 resident (R) (R1) of 1 resident in a sample of 4 residents.R1 and their family filed a grievance with the facility on 3/26/26 that involved allegations of abuse/neglect. The facility did not report the allegations of abuse/neglect to the SA.Findings include:The facility's Patient Abuse, Neglect, Mistreatment, Misappropriation of Property and Exploitation policy, dated 3/2026, indicates: Alleged Violation: is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or other but has not been investigated .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting… […]