Cedars the

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Sep 13, 2024

  Based on observation, interview, and record review the facility failed to ensure food items were laebled and stored to prevent contamination and hand hygiene was performed consistently. 39 of 39 residents residing in the facility were served food prepared in the kitchen. Findings include: During an observation and interview on [DATE] at 9:16 AM, a container of chopped lettuce was observed in an assembly area with no date on the container. The lettuce was observed to have brown and yellow edges. [NAME] 2 indicated the lettuce appeared old and should not be used. A container of grape tomatoes was observed in the assembly area with no date on the container. A package of polish sausage was wrapped in foil in the freezer with no date found on the package. […]

• No harm, potential for more than minimal, widespreadF812Sep 8, 2023

  Based on observation, interview, and record review the facility failed to ensure kitchen sanitation was maintained. 33 of 33 residents currently residing in the facility consumed food prepared in the facility kitchen. Findings include: During an observation on 9/5/23 at 6:00 AM a container of buttermilk was observed in the walk-in cooler. The container was about half full and a thick white substance was observed on top of the liquid that was a yellowish white. The date stamped on the container was 8/15/23. A container labeled lemon pudding indicated the expiration date was 9/3/23. A container labeled cherry pie filling indicated the expiration date was 8/22/23. A container labeled marshmallow sauce indicated the expiration date was 9/1/23. […]

• No harm, potential for more than minimal, widespreadF880Jan 20, 2021

  Based on observation, interview, and record review the facility failed to ensure measures to prevent the potential spread of COVID-19 were in place according to current CDC guidelines. Six of twenty three staff observed were not masked appropriately. This had the potential to effect 29 of 29 residents residing in the facility. Findings include: 1. During an observation on 1/20/21 at 11:14 A.M., Licensed Practical Nurse (LPN) 2's mask was below her nose. She was about 4 feet from another staff member. They were conversing in the common area During an observation on 1/20/21 at 12:29 P.M., Housekeeping 3's mask was below her nose while in the doorway of a resident room on the south hall. During an observation on 1/20/21 at 12:30 P.M., LPN 2's mask was below her nose. […]

• No harm, potential for more than minimal, patternF727Sep 8, 2023

  Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours in the facility 11 days of 60 reviewed. Finding includes: On 9/6/23 at 11:24 AM staff schedules for the nursing department were reviewed from 8/1/23 to 9/1/23. The staffing schedule for 8/6/23 indicated 2 agency License Practical Nurses (LPN) worked during the 24 hours. No Registered Nurse (RN) worked on 8/6/23 for 8 consecutive hours. The staffing schedule for 8/13/23 indicated 2 agency LPNs worked during the 24 hours. No RN worked on 8/13/23 for 8 consecutive hours. The staffing schedule for 8/20/23 indicated 2 agency LPNs worked during the 24 hours. […]

• No harm, potential for more than minimal, isolatedF684Sep 2, 2025

  Based on observation, interview and record review, the facility failed to ensure physician orders were followed for 3 of 12 residents reviewed (Resident 7, Resident 18 and Resident 20).Findings include: Resident 7's record was reviewed on 8/29/25 at 12:29 PM. Diagnoses included atrial fibrillation (irregular heartbeat that leads to blood clots) and anemia. Resident 7's Comprehensive Minimum Data Set (MDS), dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 9 (moderate cognitive impairment). A physician order, dated 7/1/25, indicated Resident 7 was to be administered warfarin sodium (warfarin) 4 milligrams (mg) every Monday, Tuesday, Wednesday, Thursday and Friday for prevention of blood clots. […]