Cedarwood Plaza

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 15, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, resident and staff interview, review of a police report and review of facility policy, the facility failed to provide a safe environment free from a potential accident hazard when State tested Nursing Assistant (STNA) #563 was found to have an unsecured loaded firearm in the facility. This resulted in Immediate Jeopardy and potential for serious life-threatening harm when STNA #563 left a loaded firearm, with additional rounds of ammunition, wrapped in a fleece vest and in a clear plastic bag, unsecured on a cart on the 3 North Hallway where residents resided and had access to the bag. […]

• No harm, potential for more than minimal, widespreadF812Aug 30, 2025

  Based observation, staff interview, and policy review, the facility failed to maintain the kitchen in a clean and sanitary condition. This had the potential to affect all 104 residents residing in the facility. The facility census was 104.Findings include:Observation of the kitchen area with Dietary Aide (DA) #750 on 08/30/25 beginning at 9:02 A.M. revealed the following that was verified at the time of discovery.Observation of the walk-in cooler revealed a spiral ham with no date, an onion chopped in half and stored in plastic wrap with no date, a large plastic container of diced turkey with no date, a metal container with butter that had no label or date, a metal container of bacon bits with no label or date, and a large plastic container of fat from the preparation of a beef roast with… […]

• No harm, potential for more than minimal, widespreadF814Aug 30, 2025

  Based observation and staff interview, the facility failed to maintain its dumpster area in a clean and sanitary condition. This had the potential to affect all 104 residents residing in the facility. The facility census was 104.Findings include: Observation of the outside dumpster area with Dietary Aide (DA) #750 on 08/30/25 beginning at 9:45 A.M. revealed to the left of the dumpster area, outside of the physical dumpster, were significant amounts of debris, including plastic gloves, used plastic silverware, paper plates (many with noticeable food residue), brown bags, and various other pieces of plastic laying around. In front of the dumpster, approximately fifteen feet away, was a cardboard box on the ground and the box appeared to have been run over multiple times by vehicles. […]

• No harm, potential for more than minimal, widespreadF803Jul 1, 2025

  Based on observation, record review, and interviews, the facility failed to ensure the correct serving sizes and all menu items were provided per the menu. This affected four residents (#28, #43, #55, and #99) but had the potential to affect all residents, except two residents (#36 and #51) who received nothing by mouth. The facility census was 101. Findings include: Interviews on 07/01/25 between 9:44 A.M. and 1:18 P.M. with Residents #28, #55, and #99 revealed they received small portions at mealtimes, but also stated they never knew what was on the menu prior to receiving meals. Review of the menu revealed lunch for 07/01/25 was deli meat and cheese sandwich, creamy coleslaw, and four ounces (oz) of cinnamon apple slices. […]

• No harm, potential for more than minimal, widespreadF812Jul 1, 2025

  Based on observation, interview, and record review, the facility failed to dry silverware and serve food in a sanitary manner. This had the potential to affect all residents except two (#36 and #51) who received nothing by mouth. The facility census was 101. Findings include: Observations on 07/01/25 at 12:19 PM observed Dietary Aide (DA) #409 using a dish cloth to dry the silverware that was in a tray sitting on the end of the steam table. DA #409 proceeded to place the silverware after drying them in a silverware holder. DA #409 verified the observation and stated she didn't know they weren't supposed to dry them that way. Observations on 07/01/25 at 12:20 P.M. […]