Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Crest Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified multiple infection control deficiencies, including a dusty oxygen concentrator filter for a resident with COPD, failure by two LVNs to perform hand hygiene before administering eye and nasal medications, and the presence of unlabeled personal care items in a bathroom shared by four residents. Staff confirmed these practices were not in line with facility policies.
The facility failed to develop and implement comprehensive, resident-centered care plans for six residents. The care plans lacked specific activities and measurable objectives, despite known preferences. This was confirmed by both the AD and RNS during interviews and record reviews.
The facility failed to maintain kitchen utensils and equipment in good condition, as ten baking pans and a magnetic knife holder were found dirty and rusty. The dietary supervisor verified the condition and removed the baking pans, while the registered dietitian confirmed the need for cleanliness and maintenance according to the facility's sanitation policy.
The facility's QAPI program was found ineffective in identifying and preventing medication administration errors. Observations revealed multiple instances where LVNs deviated from prescribed dosages and manufacturer guidelines, leading to improper administration of Flonase, Alphagan, and MiraLAX. The Assistant Administrator was unaware of these issues, and no performance improvement projects were in place to address them.
A resident with dysphagia was fed by a CNA who was standing, contrary to facility policies requiring staff to sit at eye level to promote dignity. This was confirmed by both the CNA and an LVN present.
The facility failed to document a resident's advance directive, leaving section D of the POLST form blank and not including a care plan. Both the Social Service Director and Registered Nurse Supervisor verified the lack of documentation.
The facility failed to accurately complete the discharge MDS for a resident, who was discharged to home with home health services. The MDS incorrectly indicated that the resident was discharged to a short-term general hospital. This error was confirmed by the social service director, the MDS Coordinator, and the registered nurse supervisor.
A resident with chronic respiratory failure was prescribed oxygen at 2 LPM, but observations revealed the oxygen concentrator was set at 4 LPM. Staff confirmed the discrepancy and acknowledged the need to follow the physician's order.
The facility failed to consistently complete the dialysis communication form for a resident with end-stage renal disease, leading to incomplete documentation of vital signs and blood sugar levels. This failure was confirmed by the nurses involved and was against the facility's policy for the care of dialysis residents.
The facility reported a medication error rate of 13%, with errors observed in the administration of Flonase, Alphagan, and MiraLAX by LVNs. Errors included incorrect dosages, failure to follow manufacturer guidelines, and incomplete administration.
The facility failed to implement proper infection control practices when a laundry staff member did not perform hand hygiene before handling clean linens and a CNA did not change gloves or perform hand hygiene during a resident's wound treatment. These actions were confirmed by the maintenance director and the infection preventionist, as well as the CNA and LVN involved in the treatment.
Infection Control Lapses in Equipment Cleaning, Hand Hygiene, and Labeling of Personal Care Items
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. The filter of a resident's oxygen concentrator was observed to be dusty, and both the licensed vocational nurse and the infection preventionist consultant confirmed that the filter should be kept clean and cleansed weekly, as per the user manual. Additionally, during medication administration, a licensed vocational nurse did not perform hand hygiene before donning gloves to administer eye drops to a resident, contrary to facility policy. In another instance, a different licensed vocational nurse did not cleanse her hands or change gloves before administering nasal spray to a resident after repositioning him, which was also against facility policy. Furthermore, during room rounds, multiple unlabeled personal care items, including wash basins, bed pans, urinals, and a kidney-shaped basin with a toothbrush and toothpaste, were found in a shared bathroom used by four residents. A certified nursing assistant confirmed that these items were in use and not labeled with resident names or room numbers, increasing the risk of cross-use. The infection preventionist consultant stated that these items should have been labeled before use, in accordance with facility policy requiring all bed pans and urinals to be marked for individual use.
Failure to Develop Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for six residents. For Resident 37, the care plan did not include specific activities that would be provided, such as daily room visits and watching television, despite the resident's preferences being known. This lack of detail in the care plan was confirmed by both the Activity Director (AD) and the Registered Nurse Supervisor (RNS) during interviews and record reviews. Similarly, Resident 1's care plan was found lacking in specific activities, such as watching television, going outside daily, and smoking outside, which were known preferences. The AD and RNS both verified that the care plan was not comprehensive and resident-centered, lacking measurable objectives and timetables to meet the resident's needs. This was also the case for Resident 53, whose care plan did not include activities like room visits, aroma therapy, blessings, and prayers, despite these being part of the resident's routine. The same deficiencies were observed for Residents 71, 41, and 2. Resident 71's care plan did not include specific activities like watching television and daily room visits. Resident 41's care plan missed activities such as talking to staff, socialization, and watching movies. Resident 2's care plan did not include activities like current events, watching television, and using an iPad. In all cases, the AD and RNS confirmed that the care plans were not comprehensive and resident-centered, lacking measurable objectives and timetables to meet the residents' physical, psychosocial, and functional needs.
Failure to Maintain Kitchen Utensils and Equipment in Good Condition
Penalty
Summary
The facility failed to ensure that kitchen utensils and equipment were maintained in good condition and stored in accordance with professional standards for safety. During an initial kitchen tour, ten baking pans were observed with brownish to dark colored spots that appeared dirty and rusty. Additionally, a magnetic knife holder with attached kitchen knives was found to have brownish discolorations that also looked dirty and rusty. These observations were made in the presence of the dietary supervisor (DS), who verified the condition of the items and removed the baking pans immediately. The DS also acknowledged the condition of the magnetic knife holder and stated that it would be cleaned. The registered dietitian (RD) later confirmed that baking pans and the magnetic knife holder should be kept clean and free of rust. The facility's undated policy and procedures on sanitation indicated that all utensils, counters, shelves, and equipment should be kept clean, maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. The failure to maintain these items in good condition had the potential to cause the growth of microorganisms and cross-contamination of food, which could affect the 81 residents residing and consuming food at the facility.
Medication Administration Errors and Ineffective QAPI Program
Penalty
Summary
The Quality Assessment Performance Improvement (QAPI) program at the facility was found to be ineffective in identifying and preventing medication administration errors. During a medication pass observation, a 13% medication error rate was noted. Specifically, a Licensed Vocational Nurse (LVN A) administered Flonase to a resident but deviated from the prescribed dosage by spraying two sprays in each nostril instead of one. Additionally, LVN A did not follow the manufacturer's guidelines for administering the nasal spray, such as instructing the resident to blow their nose or closing the opposite nostril during administration. LVN A admitted to the errors and attributed them to initial confusion and forgetfulness about the proper guidelines. Further observations revealed that LVN A also improperly administered Alphagan ophthalmic solution to the same resident by allowing the tip of the eye drop bottle to contact the eyelashes, increasing the risk of contamination. LVN A did not instruct the resident to keep their eyes closed or press their index finger against the inner corner of the eye after administration, as recommended by the manufacturer. LVN A acknowledged these errors during an interview and expressed a commitment to improving their practices. Additional deficiencies were observed with other nurses. LVN B administered MiraLAX to a resident but did not mix it thoroughly, resulting in the resident not consuming the full dose. Similarly, LVN C administered MiraLAX to another resident, who only took a small sip, and LVN C left without ensuring the medication was fully consumed. The Assistant Administrator, involved with the QAPI program, was unaware of any medication administration issues and confirmed that the program had not identified or addressed such concerns. There was no documented evidence that medication administration errors were being reviewed or that performance improvement projects were in place to address these errors.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to treat Resident 390 with respect and dignity when Certified Nurse Assistant E (CNA E) was observed standing while feeding the resident. Resident 390, who had been admitted with a diagnosis of dysphagia (difficulty swallowing), was being fed by CNA E while CNA E was standing over him. This observation was confirmed by both CNA E and Licensed Vocational Nurse J (LVN J), who was present in the room for medication administration. The facility's policies and procedures on dignity and assistance with meals explicitly state that residents should be fed in a manner that promotes their well-being and dignity, including not standing over them while feeding. However, these guidelines were not followed in this instance, leading to a deficiency in the care provided to Resident 390.
Failure to Document Resident's Advance Directive
Penalty
Summary
The facility failed to document the status of a resident's advance directive (AD) for one of seven residents investigated. Resident 2 was admitted with diagnoses including angioneurotic edema, unspecified heart failure, and unspecified hyperlipidemia. The clinical records for Resident 2 did not contain documentation verifying or obtaining an advance directive, nor was there a care plan regarding the advance directive. Additionally, the Physician Orders for Life-Sustaining Treatment (POLST) form for Resident 2 had all options in section D, which pertains to advance directives, left blank. During a concurrent record review and interview with the Social Service Director (SSD) and the Registered Nurse Supervisor (RNS), both verified that section D of Resident 2's POLST was left blank and that there was no documentation or care plan regarding the advance directive. The facility's policy and procedures on advance directives state that information about whether or not the resident has executed an advance directive should be prominently displayed in the medical record, which was not done in this case.
Incorrect Discharge MDS Coding
Penalty
Summary
The facility failed to accurately complete the discharge Minimum Data Set (MDS) for one resident, which had the potential to compromise the facility's ability to provide resident-centered discharge care planning and interventions. Specifically, Resident 79 was admitted with multiple diagnoses, including a displaced intertrochanteric fracture of the left femur, atrial fibrillation, and essential primary hypertension. The resident was discharged to home with home health services, but the MDS incorrectly indicated that the resident was discharged to a short-term general hospital. Interviews and record reviews confirmed the incorrect coding. The social service director, the Minimum Data Set Coordinator, and the registered nurse supervisor all verified that the discharge MDS was incorrectly coded. The error was identified during a review of the resident's face sheet, interdisciplinary team planned discharge summary report, and section A of the MDS. The coding error was acknowledged by the staff, who confirmed that the resident was indeed discharged to home with home health services, not to a short-term general hospital.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards of practice for Resident 390. The resident, who had a diagnosis of chronic respiratory failure, was prescribed oxygen at 2 liters per minute (LPM) via a nasal cannula. However, during observations on two separate occasions on the same day, the oxygen concentrator was set at 4 LPM, which was confirmed by Licensed Vocational Nurse J. The nurse acknowledged that the oxygen should have been administered at the prescribed rate of 2 LPM as per the physician's order. Further interviews with the Registered Nurse Supervisor confirmed that staff should ensure oxygen is administered at the prescribed rate. A review of the facility's policies and procedures indicated that a physician's order is required for therapies and treatments, including oxygen administration. The failure to adhere to the physician's order for oxygen administration had the potential to compromise the resident's health and safety.
Failure to Complete Dialysis Communication Forms
Penalty
Summary
The facility failed to consistently complete the dialysis communication form for a resident who required dialysis services. The resident, who had end-stage renal disease and received dialysis on specific days, had incomplete documentation on the dialysis communication forms. Specifically, there was no documentation of vital signs on one occasion and no documentation of blood sugar on another occasion. These forms were supposed to be filled out by the licensed nurse receiving the resident from dialysis, but this was not done consistently, as confirmed by the nurses involved during interviews and record reviews. The facility's policy and procedure for the care of dialysis residents required that vital signs be taken upon the resident's return from dialysis. However, this policy was not followed, as evidenced by the incomplete forms. The nurses involved acknowledged that they should have completed the forms as required. This failure had the potential to compromise the facility's ability to identify and address potential complications after dialysis for the resident involved.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with a reported error rate of 13%. During a medication pass, four medication errors were observed out of thirty opportunities for three of seven residents. One incident involved a Licensed Vocational Nurse (LVN A) administering two sprays of Flonase in each nostril to a resident instead of the prescribed one spray, and not following the manufacturer's guidelines for proper administration. LVN A admitted to the discrepancy and acknowledged the error during an interview. Another incident involved LVN A administering Alphagan ophthalmic solution to the same resident but failing to follow the manufacturer's guidelines, including allowing the tip of the eye drop bottle to contact the eyelashes and not instructing the resident to keep their eyes closed for 1 to 2 minutes after administration. LVN A admitted to forgetting the proper procedure during the administration. Additionally, two separate incidents involved LVNs B and C administering MiraLAX to two different residents. LVN B did not thoroughly mix the MiraLAX solution, resulting in the resident consuming less than half of the mixture, while LVN C did not ensure that the resident fully consumed the MiraLAX mixture, leaving most of it in the glass. Both LVNs admitted to their respective oversights and acknowledged the need for improvement in their administration practices.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection control practices in two observed instances. In the first instance, a laundry staff member did not perform hand hygiene before handling clean linens and residents' personal clothing. This was observed during an interview with the maintenance director, who confirmed that all laundry staff should wash their hands before handling clean items. The infection preventionist emphasized the importance of hand hygiene in preventing the spread of infections. The facility's policy on hand hygiene was reviewed and indicated that hand hygiene is the primary means to prevent the spread of infections and should be performed before and after coming on duty. In the second instance, staff failed to perform hand hygiene during the treatment of a resident with a pressure ulcer and a surgical wound. The certified nurse assistant did not change gloves or perform hand hygiene between different stages of the wound treatment, despite handling both the resident and the wound dressings. This was confirmed by both the CNA and the licensed vocational nurse involved in the treatment. The facility's policy on hand hygiene was reviewed and indicated that hand hygiene should be performed before and after direct contact with residents and before handling clean or soiled dressings.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sunnyvale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunnyvale Gardens Post Acute | 0.6 mi | — | 0 | 0 |
| Idylwood Care Center | 2.2 mi | — | 0 | 0 |
| Sunnyvale Post-acute Center | 2.2 mi | — | 3 | 0 |
| Sunny View Manor | 3.4 mi | — | 0 | 0 |
| Courtyard Care Center | 3.4 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.