Cedar Manor Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 5, 2022

  Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of four residents reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident #1. As a result, he eloped from the facility and was picked up by a police officer 30 minutes later in 22° Fahrenheit weather approximately 2 blocks from the facility. An Immediate Jeopardy (IJ) was determined to have existed from 02/23/22 to 03/01/22. […]

• No harm, potential for more than minimal, widespreadF812Jun 25, 2021

  Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure: Holding temperatures were taken of the meal prior to serving; Food was labeled and dated so they could be thrown out when appropriate; Food was not freezer-burned or wilted The pantry was deep cleaned according to the facility schedule; Effective hair-restraints were worn; These deficient practices could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross contamination. […]

• No harm, potential for more than minimal, patternF680Mar 5, 2026

  Based on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a therapeutic recreation specialist or an activity professional for 1 of 1 activity director (AD) reviewed for qualifications. The facility failed to ensure the AD was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings included: Interview on 03/05/2026 at 11:05 AM the AD said she had been working at the facility as the AD since April 2025. […]

• No harm, potential for more than minimal, patternF812Mar 5, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen as evidence by: The facility failed to ensure:A. Dietary Manager and [NAME] D wore a hair restraint properly covering all of their hair. B. The bottom shelves throughout the kitchen were clean and not soiled.C. The stove and oven were clean and not soiled. D. The vent hood was clean and free of dust.E. The freezer in the pantry was clean and not soiled.F. The shelves in the pantry were clean and free of dust. […]

• No harm, potential for more than minimal, patternF880Mar 5, 2026

  Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #3 and #21) of 5 residents reviewed for infection control. LVN A failed to sanitize the glucometer after she performed a blood sugar test on Resident #21. CNAs B and C failed to use recommended PPE when they assisted Resident #3 with incontinent care and urinary catheter care as the resident was on EBP precautions. […]