Cedar Manor Nursing Home

Based on observations, facility policy review and staff interviews, the facility failed to provide a dignified eating experience for six of six resident's (Resident #21, 32, 38, 41, 43, 50) who ate their plated meals while they remained on a serving tray, The facility reported a census of 50 residents.Findings include:During an observation on 11/17/2025 at 12:16 PM, six residents in the Assisted Dining Room (ADR) ate their meal, while it sat on a tray. During an observation on 11/18/25 at 11:58 AM, all residents seated at the tables in the ADR were served their meal on trays. Their plate left on the tray while they ate. During an observation on 11/19/2025 at 12:15 PM, six out of the six residents in the ADR sat at a table while their plated meals sat on the tray. Staff C and Staff D, Certified Nursing Assistants (CNA's) sat and fed two of the six residents. On 11/20/2025 at 9:59 AM, Staff C, CNA reported Resident's #21, 32, 38, 41, 43, and 50 ate in the ADR on 11/17/25, 11/18/25 and 11/19/25. She confirmed all the residents in the ADR ate their meals off a plate which sat on a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, equipment manual review, resident and staff interviews, the facility failed to transport residents in the hallways in a safe manner for 2 of 2 residents (Resident #17 and Resident #53) reviewed for safety. The facility reported a census of 50 residents.Findings include:1. The Minimum Data Set (MDS) for Resident #17 dated 10/7/25 documented diagnoses of other idiopathic scoliosis in the lumbar region, atrial fibrillation, and Alzheimer's disease. The resident scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. Resident #17 assessed dependent on a wheelchair for mobility and dependent on staff for transfers.During an observation on 11/19/2025 at 1:44 PM, Staff A, Certified Nursing Assistant (CNA) pushed the Resident #17 in her wheelchair from a table in a common area to the dining room for an activity. During the transport, Resident #17's right foot rested on a foot pedal, while the left foot dropped down between the right pedal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of resident council minutes, facility policy review, resident and staff interviews, the facility failed to answer call lights within 15 minutes to meet resident needs for 2 of 2 residents (Resident #5 and Resident #49) reviewed for call lights. The facility reported a census of 50 residents.Findings include:1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 6/05/24. The list of diagnoses included heart failure, adjustment disorder with depressed mood, benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate gland presses on the urethra), and pain. The MDS indicated Resident #5 utilized a wheelchair for mobility, dependent on staff for transfers and toileting hygiene. The Brief Interview for Mental Status (BIMS) assessment score of 11 out of 15 indicated a moderate cognitive impairment. Review of Resident #5's Care Plan, dated 9/17/25, revealed the following Focus area's:a. I have an ADL (Activities of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, staff interview and facility policy review the facility failed to provide the Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) to one out of three resident in a timely fashion (Resident#16). The facility reported a census of 50 residents. Findings include: The Clinical Census sheet for Resident #16 identified the start of the Skilled Nursing Facility (SNF) services on 5/10/24 and ended on 5/28/24. A Progress Note dated 5/28/24 at 10:59 AM revealed Resident#16 on SNF level of care until 5/29/24. The Progress Notes dated 5/27/24 and 5/26/24 did not include documentation regarding communication with the resident or her responsible party regarding the discharge from SnF services and the right to appeal. The CMS 10123 (Notice of Medicare Non-Coverage or NOMNC) form signed by Resident#16 responsible party reflected a dated of 5/29/24. The CMS 10055 (SNFABN) form signed by Resident#16 responsible party reflected a dated of 5/29/24. On 10/2/14 at 3:50 PM the Administrator reported she expected the Advanced Beneficiary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure an indwelling catheter collection bag placed in a dignity cover, with the bag and bag remained off the floor to prevent urinary tract infections for one of one resident (Resident #39) reviewed with an indwelling catheter. The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], list of diagnoses included: congestive heart failure, dementia and sacral pressure ulcer. A Brief Interview for Mental Status score of 10 out of 15 indicated a moderate cognitive impairment. The MDS identified Resident #39 used an indwelling catheter (for urine collection). Review of admission Orders, dated 9/23/24, revealed an order admission for hospice. The orders also included an Indwelling Foley catheter for comfort. The Care Plan, dated 9/30/24, included a Focus area to address Indwelling Foley Catheter: 16F (French - catheter size) for comfort r/t Terminal condition. Interventions included: Check…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility policy review, resident, family, and staff interview, the facility failed to treat two of eight residents reviewed with dignity and respect (Residents #1 and #5). The facility reported a census of 51 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. The MDS included diagnoses of Alzheimer's disease, anxiety disorder and unspecified atrial fibrillation (an abnormal heart rhythm). Resident #1 required substantial/maximal assistance with oral hygiene, toilet use, and showers. Resident #1 required total assistance from staff for lower body dressing, putting on and taking off footwear. The Care Plan Focus revised 4/16/24 identified Resident #1 had a problem of impaired cognitive function related to dementia and forgetfulness. The Health Status Note dated 4/15/24 at 9:38 PM indicated a certified nurse aide (CNA) notified the nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview and facility policy review, the facility failed to update Care Plans for three of eight residents reviewed. (Residents #1, #2, and #4). The facility failed to update the residents Care Plans after the staff discovered Resident #1 had an injury of unknown origin. After Resident #2 sustained burns to her thighs after she spilled coffee on her lap. Then after Resident #4 had a choking episode which required the Heimlich maneuver (first-aid treatment used to try to remove a blockage from someone's airway). The facility reported a census of 51 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. Resident #1 required substantial/maximal assistance with oral hygiene, toilet use, and showers. Resident #1 required total assistance from staff for lower body dressing, putting on and taking off footwear. The MDS included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interview the facility failed to transport leftover food items from the East Kitchenette down the hallway to the Main Kitchen in accordance with professional standards of practice for infection control and food safety, by not properly covering the food transported. The facility reported a census of 44 residents. Findings Include: 1. On 6/26/23 at 12:09 PM, the Dietary Staff observed transferring leftover food from the East Kitchenette down the facility hallway to the Main Kitchen on a three shelf wheeled cart. The leftover food containers noted to be uncovered with kitchen utensils still in the containers. Once inside the Main Kitchen the Dietary Staff discussed with the [NAME] about the leftover food. 2. On 6/27/23 at 12:11 PM, the East Kitchenette leftover food observed being returned to the kitchen by Staff A, Dietary Staff. The leftover food noted uncovered on a cart and transferred down the facility hallway to the Main Kitchen. Outside of the Main Kitchen, Staff A asked about the leftover food and what the process was when the leftovers were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and Dietary documentation review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety as evidenced during the brief Initial Tour of the kitchen and follow up visits to the kitchen. The facility reported a census of 44 residents. Findings Include: 1. On 6/26/23 at 9:53 AM, a brief Initial Tour of the Main Kitchen revealed the following concerns: a. A Vulcan gas stove with build up grim within the six burners of the stove. The back wall ledge of the stove approximately 3 inches in height noted with visible grime and grease across the length of wall. b. A Vulcan oven next to the stove had a build up of grime vertically streaked down the right side panel of the oven. The temperature dial, all oven door crevices observed to have grime and dust build up. c. The Vulcan oven and an adjoining table with a small steam oven had an open bottom that showed visible pieces of food and dirt on the floor that had not been swept up. d. Across from the Vulcan range and ovens, a food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observations, resident and staff interviews and facility policy review the facility failed to report one out of one allegation of abuse to the state agency (Resident # 96). The faculty reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident #96 dated 10/20/22, listed diagnoses of congestive heart failure, and respiratory failure. The Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating intact cognition. The Incident Report dated 12/12/22 at 9:00 PM, reflected Resident #96 reported a Certified Nurses Aid (CNA) hit her in the face with a closed fist. The Incident Report revealed the Administrator signed the document on 12/13/22. On 06/26/23 at 2:30 PM, Resident #96 stated, Staff F, Certified Nurses Aid, (CNA) punched her in the face. Resident #96 revealed that hurt her pride, hurt her face, and she felt disrespected. On 6/26/23 at 2:30 PM, Resident #96 hands shook and she appeared upset as she described the incident On 06/28/23 at 11:14 AM, Staff G, CNA stated she knew Resident #96…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observations, staff interviews and facility manual review the facility staff failed to complete a Significant Change Minimum Data Set (MDS) Assessment when a resident developed a pressure area for 1 out of 1 residents reviewed with pressure sores (Resident #8) and when the same resident had a significant weight loss for 1 out of 12 residents reviewed for weight loss (Resident #8). The facility reported a census of 44 residents. Findings Include: The MDS Assessment for Resident #8 Dated 4/13/23, included diagnoses of non- Alzheimer's dementia, malnutrition, and altered mental status. The MDS revealed Resident #8 lacked pressure ulcers/wounds at the time of the MDS, and identified her risk for pressure ulcers. The MDS reflected Resident #8's weight at 137.8 pounds. The Skin/Wound Note dated 6/6/2023 at 4:21 PM, identified Resident #8 presented with Stage 2 Pressure Ulcer open area on buttocks 2.3 centimeters (cm) by 0.9 cm by 0.1 cm deep. No drainage from the wound. The surrounding skin appeared pink. The wound bed contained granulation tissue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.