Cedars Health Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 22, 2025

  Based on facility policy review, record review and interviews, the facility failed to ensure a resident's right to be free from neglect for one (1) of four (4) sampled residents, Resident #1.On 10/14/25 at approximately 10:16 AM, after returning to the facility from an appointment the facility abandoned Resident #1 on the facility's transport van. Resident #1 was left alone and unattended on the facility transport van for approximately two hours. At 12:15 PM, the facility staff located Resident #1 still strapped in the facility transport van. […]

• No harm, potential for more than minimal, patternF656Nov 20, 2025

  Based on observation, resident, staff, and family interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for personal hygiene and grooming for five (5) of 28 sampled residents. Resident #4, #10, #34, #60, and #92 Findings Include: Review of the facility policy titled Comprehensive Care Plans unrevised, revealed under, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan Resident #4 Record review of Resident #4's Care Plan Report revealed that he needed assistance with ADL's (Activities of Daily Living) related to recent hospitalization for left femur fracture, total hip arthroplasty d/t autoimmune encephalitis, falls, episodes of confusion. […]

• No harm, potential for more than minimal, patternF677Nov 20, 2025

  Based on observation, staff, resident, and resident representative interview, record review, and facility policy review, the facility failed to provide nail care (Resident#10 and Resident #92), and shaving (Resident#4, Resident #34, Resident #60 and Resident #92) for five (5) of 28 sampled residents. Resident #4, #10, #34, #60, and #92Findings Include: Review of the facility policy titled Activities of Daily Living unrevised, revealed under, Policy Explanation and Compliance Guidelines: . 2. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #4 During an observation on 11/17/25 at 11:00 AM it was revealed that Resident #4 was lying in bed unshaved. […]

• No harm, potential for more than minimal, isolatedF584Nov 20, 2025

  Based on observation, staff interview, and facility policy review, the facility failed to maintain a wheelchair in a clean and sanitary manner for one (1) of seven (7) residents using mobility devices in house 600. Resident #92 Findings Include: Review of the facility policy titled Safe and Homelike Environment unrevised, revealed under, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. An observation of Resident #92 on 11/17/25 at 11:35 AM revealed she was sitting in her wheelchair in the front lobby area. […]

• No harm, potential for more than minimal, isolatedF761Nov 20, 2025

  Based on observation, staff interview, record review, and facility policy review, the facility failed to monitor refrigerated medications for proper temperature control to ensure safe medication storage for one (1) of 11 medication refrigerators in facility. Rehabilitation Unit refrigerator Findings include: Record review of the facility policy titled, Storage of Medication Requiring Refrigeration, dated 4/2025 revealed, It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls. Refrigerators used for the storage of medications and biologicals: e. Temperature should be maintained between 36 - 46 degrees F (Fahrenheit). f. […]