Complete Care at Cedar Grove

In the surveyor’s words

From the most serious findings on record at Complete Care at Cedar Grove, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 22, 2026

  Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness.This deficient practice was evidenced by the following: 1. On 5/6/26 at 9:38 AM, Surveyor #1 and #2, in the presence of the Food Service Director (FSD), observed the following during the initial kitchen tour: The snack refrigerator which stored health shakes, sandwiches, and other snacks, had an external temperature on the refrigerator of 40 degrees Fahrenheit (F) and an internal thermometer reading observed at 54 F. The FSD acknowledged the reading was not an acceptable temperature and stated the temperature should be between 35-40 F. […]

• No harm, potential for more than minimal, widespreadF809Aug 18, 2023

  Based on observation, interview, review of the facility's meal schedule, and facility policy review, the time span between the residents' evening meal and the following breakfast meal exceeded 14 hours and the time span between these two meals was not approved by five of five residents (Resident (R) 47, R49, R53, R61, and R118) who regularly attended the monthly resident council meetings and were interviewed regarding the facility's meal schedule. This failure had the potential to affect 164 residents who received meals from the facility's kitchen. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF812Aug 18, 2023

  Based on observation, interview, and facility policy review, the facility failed to ensure coffee pitchers and the juice machine's dispenser nozzle were dry when stored, kitchen ceiling tiles were free of mold, kitchen storage racks were clean and kitchen sanitizing buckets contained adequate quaternary ammonia to sanitize kitchen equipment and food preparation surfaces. This failure had the potential to affect 164 residents who consumed food prepared from the facility's kitchen. Findings included: 1. Observation during the initial kitchen inspection on 08/14/23 from 9:00 AM to 9:40 AM, with Director of Food Services (DFS) present, revealed the following: a. Four coffee pitchers with their lids tightly closed were stored wet with accumulated water in each pitcher. b. […]

• No harm, potential for more than minimal, widespreadF868Aug 18, 2023

  Based on interview and review of facility documentation, the Quality Assurance and Performance Improvement (QAPI) committee failed to hold quarterly meetings for one of four QAPI meetings conducted. This failure had the potential to affect all 170 residents who currently live in the facility. Findings include: Review of the facility QAPI sign-in log dated 12/14/22 was for the third quarter of 2022 that included July 2022, August 2022, and September 2022. Review of the facility's QAPI sign-in log dated 01/25/23 was for the fourth quarter of 2022 that included October 2022, November 2022, and December 2022. […]

• No harm, potential for more than minimal, patternF584May 22, 2026

  Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a homelike environment. Specifically, the facility failed to: a) keep the facility's environment in an adequate state of repair on 1 of 4 nursing care units surveyed, and b) failed to clean and maintain the equipment and furnishings of 4 of 32 residents (Residents #15, #93, #154 and #183) reviewed for homelike environment.The deficient practice was evidenced by the following: 1.) On 5/6/26 at 10:45 AM, the surveyor observed in Resident #154's room, to left of the door inside the room, there were dark brown splatters on the wall about 5 feet up from the floor, light brown dry splatters noted on the base of tube feeding pole, the oxygen concentrator, the wall… […]