The Villas at the Cedars

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Jan 27, 2026

  Based on interview and document review, the facility failed to ensure a medication was available for administration for 1 of 3 residents (R1) reviewed for medication errors. This resulted in immediate jeopardy (IJ) when R1 was not administered physician prescribed anti-seizure medication which resulted in hospital intensive care unit (ICU) admission for medical management and treatment. The IJ began on 1/17/26 when the facility failed to ensure R1 received scheduled dose Lacosamide (anti-seizure medication) on 1/17/26, 1/18/26, and 1/19/2026 (six doses) and an additional dose not administered on morning of 1/20/26 this caused R1 to have 3 seizures over the span of 7 minutes resulting in hospital ICU admission where R1 remains. […]

• Immediate jeopardy, isolatedF684Nov 7, 2024

  Based on interview and record review, the facility failed to monitor and notify the physician following a change in condition for one of three residents, (R1) who had multiple episodes of vomiting that began on [DATE] and continued through [DATE] when R1 died . This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE] when R1's had a change in condition was not monitored, nor was the physician notified of R1's change in condition that started on the evening of [DATE] and continued through the morning of [DATE] when R1 passed away. The IJ was identified on [DATE]. The administrator and the director of nursing were notified of the immediate jeopardy at 10:47 a.m. on [DATE]. […]

• Immediate jeopardy, isolatedF689May 16, 2023

  Based on observation, interview and document review, the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 residents (R1) reviewed for missing person/elopement. This resulted in immediate jeopardy when R1 exited the facility and was found on the ground on near a street intersection on the sidewalk by law enforcement (LE)-A, late at night. The facility was unaware of R1's absence from 11:20 p.m. until 11:47 p.m. which placed him at risk for serious harm, impairment, or death. The immediate jeopardy began on 4/29/23 at 11:20 p.m., when R1 left the facility unsupervised and was found at 11:47 p.m., outside the facility on the on the ground by law enforcement (LE)-A. […]

• Actual harm, isolatedF692Aug 5, 2025

  Based on interview and document review, the facility failed to comprehensively and accurately re-assess, develop and implement interventions to reduce/prevent significant and continued weight loss for 1 of 3 resident (R2) reviewed for weight loss. This resulted in actual harm when R2 was hospitalized for malnutrition. Findings Include: Center for Medicare & Medicaid Services (CMS) considers weight loss ‘significant' if it exceeds 5 percent (%) within one month, 7.5% within three months, or 10% within six months. […]

• No harm, potential for more than minimal, widespreadF880Sep 19, 2024

  Based on observation, interview, and record review the facility failed to ensure personal protection equipment (PPE) was used when sorting dirty laundry. This had the potential to impact all 82 residents who reside in the facility. Findings include: During observation and interview on 9/19/24 at 10.24 a.m., Environmental Service Director (ESD) indicated the laundry aide would take the dirty laundry from the red chute in the laundry room and sort it. He indicated the staff was to wear a gown and gloves when handling dirty laundry. He indicated the gowns are to be hung on the wall in the dirty laundry room. He verified there were no gowns on the wall. Interview with laundry aide (LA) -A and LA- B at 10:35 a.m. they indicated there were no gowns, and there had not been for around a month. […]