Cedarvale Commons Rehabilitation and Healthcare Ce

In the surveyor’s words

From the most serious findings on record at Cedarvale Commons Rehabilitation and Healthcare Ce, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Sep 9, 2021

  Based on observations, staff interviews, interview with the Legionella Consultant, record reviews, review of the Certificate of Death, review of the water sample report, review of the facility's water management policy, review of the facility's Legionella water management program, and review of the facility's Legionella written plan, the facility failed to adhere to their policy and water management program to prevent the spread of Legionella. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when one resident (Resident #100) was found lethargic, with a reddened rash, cool skin, unable to answer or follow commands, and was going in and out of consciousness. Resident #100 was sent to the emergency room for evaluation. […]

• No harm, potential for more than minimal, widespreadF730Jul 9, 2025

  Based on personnel record review, staff interview, and review of facility policy and procedure, the facility failed to ensure Certified Nurse Aides (CNA) had annual performance evaluations. This had the potential to affect all facility residents. The facility census was 64. Findings include 1. Review of the employee file for CNA #120 revealed she began employment on 04/09/24 The employee file revealed no documented evidence of a completed annual performance evaluation. 2. Review of the employee file for CNA #81 revealed she began employment on 07/05/23. The employee file revealed no documented evidence of completed annual performance evaluations. Interview on 06/24/25 at 3:30 P.M. with the Director of Nursing verified no evaluations were in the employee files for CNA #81 and #120. […]

• No harm, potential for more than minimal, widespreadF803Jul 9, 2025

  Based on observation, resident interview, staff interview, review of dietary production spreadsheets, review of resident meal tickets, and review of the facility's always available menu, the facility failed to ensure portion sizes were served as planned, which had the potential to affect all residents. The facility also failed to ensure items on the always available menu were available for Resident #17 and Resident #37. This affected two residents (#17 and #37) out of 64 residents observed during dining. The facility also failed to ensure the meal served matched the meal ticket. This affected two Residents (#10 and #21) of three observed for meal tickets. The facility census was 64. Findings include: 1. Observations on 06/17/25 from 11:05 A.M. to 11:35 A.M. […]

• No harm, potential for more than minimal, widespreadF812Jul 9, 2025

  Based on observation and staff interview, the facility failed to ensure staff wore hair nets in the kitchen as appropriate. This had the potential to affect all 64 residents in the facility. Findings include: Observation on 06/16/25 at 8:25 A.M. revealed [NAME] #135 preparing food in the kitchen. [NAME] #135 had long hair, pulled back, and was not observed to be wearing a hairnet. Observation on 06/16/25 at 8:37 A.M. revealed Dietary Aid (DA) #134 pouring juice into individual glasses. DA #134 had long hair, pulled back, and was not observed to be wearing a hairnet. Interview on 06/16/25 at 8:38 A.M., [NAME] #135 verified herself and DA #134 were not wearing hair nets. […]

• No harm, potential for more than minimal, widespreadF947Jul 9, 2025

  Based on personnel record review and staff interview, the facility failed to ensure nurse aides completed 12 hours of annual in-services. This had the potential to affect all facility residents. The facility census was 64. Findings include: 1. Review of the employee file for Certified Nurse Aide (CNA) #120 revealed she began employment on 04/09/24. The employee file had no evidence of any continuing education. 2. Review of employee file for Certified Nurse Aide (CNA) #81 revealed she began employment on 07/05/23. The employee file had no evidence of any continuing education. Interview on 06/24/25 at 3:30 P.M. with the Director of Nursing verified there was no documented evidence of continuing education in the employee files for CNA #81 and CNA #120. Interview on 06/24/25 at 4:20 P.M. […]