Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Creek Health Campus during CMS and state inspections, most recent first.
Two residents with cognitive impairments and dietary orders for therapeutic or fortified diets did not consistently receive meals as prescribed by their physicians. Observations revealed that required fortified foods and specific meal components were omitted, despite care plans and dietary cards indicating these needs. The dietary manager confirmed that the appropriate fortified foods were not always provided.
A resident reported missing personal clothing items, but the facility failed to document or investigate the grievance as required by policy. Staff were aware of the missing items, yet no grievance form was completed and no follow-up was recorded in the grievance system.
A resident with multiple chronic conditions received propranolol and hydrochlorothiazide outside of the physician-ordered blood pressure and heart rate parameters on several occasions. The DON confirmed that these medications should have been held per the orders.
Two residents at risk for falls did not receive required safety interventions: one used a wheelchair with a broken brake that had not been repaired despite staff awareness, leading to a fall, and another did not have a care plan-required bathroom sign to remind her to call for assistance, with staff noting she often removed such signs.
A resident with an indwelling Foley catheter was observed with the catheter collection bag on the floor, and staff failed to document urinary output in milliliters as required, instead using qualitative terms such as 'small,' 'medium,' or 'large.' The DON confirmed there was no specific facility policy for documenting urinary output for catheterized residents.
A resident with acute respiratory failure and hypoxia was observed twice receiving oxygen at 2 LPM, despite a physician's order for continuous administration at 4 LPM by nasal cannula. An LPN confirmed the error and adjusted the flow rate to the correct setting after it was identified.
A resident with multiple chronic conditions received acetaminophen for pain on numerous occasions without documentation of pain location, severity, or use of non-pharmacological interventions prior to administration. The care plan required these steps, but medication records did not reflect them, and the DON confirmed that such documentation should have occurred.
A resident with severe cognitive impairment and a feeding tube, who was under physician-ordered Enhanced Barrier Precautions, did not have required signage or PPE bins present in their room. Staff did not visibly implement the necessary infection control measures during surveyor observations.
The facility failed to serve breakfast within 14 hours of dinner for residents in the VIP Dining Room, with breakfast being served at 10:06 a.m. due to delays in getting residents seated. Dinner was served the previous evening between 4:45 p.m. and 5:15 p.m., resulting in a gap exceeding 14 hours. The delay was attributed to CNAs' inability to get residents to the dining room on time and dietary staff waiting to serve meals until most residents were seated.
A resident with dementia frequently refused bathing, yet the facility failed to document these refusals or update the care plan to reflect this behavior. The resident had not been bathed since admission, and the DON and Social Service Director were unaware of the issue due to inadequate communication and documentation. The facility's policy for behavior assessment and intervention was not followed, leading to a deficiency in care.
A cognitively impaired resident with a history of exit-seeking behavior eloped from a facility due to inadequate supervision and a malfunctioning door alarm. The resident exited through an alarmed door that was left open by a rug, and the Wanderguard alarm was not heard by staff due to improper wiring. The resident was found 0.3 miles away and returned without injury after being assessed by EMS.
The facility failed to provide necessary ADL care for two residents. One resident had long, thickened, and discolored fingernails despite expressing a desire to have them trimmed. Another resident had grown-out facial hair and disheveled hair, with no documentation of assistance with shaving. The DON acknowledged the deficiencies and cited issues with equipment and communication.
The facility failed to monitor and assess skin discolorations for three residents, including one with atrial fibrillation and hypertension, another with dementia and pulmonary fibrosis, and a third with dementia and Parkinson's disease. Despite care plans and progress notes indicating the need for monitoring, there was a lack of follow-up and documentation on their skin conditions.
A facility failed to ensure a resident received necessary treatment to prevent a decrease in range of motion due to improperly positioned leg rests and a footboard on a wheelchair. The resident, with diagnoses including dementia and a history of falls, repeatedly attempted to place her feet on the floor but was repositioned by an Activity Aide. The DON and TD later confirmed the leg rests were not positioned correctly, leading to incidents where the resident almost tipped her chair and turned her wheelchair over.
A facility failed to ensure a g-tube was properly checked for placement before medication administration for a resident. An LPN used an air bolus instead of removing residual from the g-tube, contrary to facility policy. The LPN acknowledged the mistake, and the Director of Nursing had no further information.
The facility failed to ensure proper medication storage, with unidentified and crushed pills found in two medication carts. Night shift staff were responsible for cleaning the carts, but this was not done. The DON was informed but had no further information.
Failure to Serve Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were served as ordered by the physician for two of three residents reviewed. For one resident with vascular dementia and a severely impaired cognitive status, observations showed that breakfast and lunch meals did not consistently match the physician's order for a regular diet with fortified foods, as indicated on the meal card and care plan. The care plan specifically noted the resident was at risk for malnutrition and required the diet to be served as ordered by the physician. Another resident, diagnosed with dementia and stroke and assessed as requiring a mechanically altered and therapeutic diet, was observed receiving meals that did not align with the physician's order for a no added salt, mechanical soft diet with fortified foods. The resident's breakfast and lunch did not include the required fortified foods, and the lunch meal was missing a specified side dish. The dietary manager confirmed that fortified foods, such as yogurt or oatmeal, should have been provided but were not consistently served.
Failure to Document and Investigate Resident Grievance Regarding Missing Clothing
Penalty
Summary
A resident who was cognitively intact and required substantial assistance for bed mobility and transfers reported missing personal clothing items, specifically a baseball sweatshirt and a blue and white nightgown. The resident stated that the sweatshirt had been missing for a couple of months and the nightgown for approximately two weeks, and neither item had been found or replaced. Despite these concerns, a review of the facility's grievance records for the past six months revealed no documentation of grievances from this resident regarding the missing clothing. Interviews with facility staff confirmed awareness of the missing items, with the DON acknowledging knowledge of the situation but being unable to specify when the sweatshirt was ordered or if a grievance had been filed. The Executive Director also confirmed that the resident had reported the missing items but that no grievance form had been completed. The facility's policy requires that concerns be documented and followed up within 24-48 hours, but this process was not followed in this case.
Failure to Hold Medications per Blood Pressure and Heart Rate Parameters
Penalty
Summary
The facility failed to ensure that medications were administered or withheld according to physician orders and specified blood pressure and heart rate parameters for a resident with multiple diagnoses, including Parkinson's disease, chronic kidney disease, and congestive heart failure. The resident was assessed as moderately cognitively impaired and had physician orders for propranolol to be held if the heart rate was less than 60 beats per minute or systolic blood pressure was less than 120, and for hydrochlorothiazide to be held if systolic blood pressure was less than 120. Despite these orders, documentation showed that propranolol was administered on several occasions when the resident's blood pressure and/or heart rate were below the specified thresholds. Similarly, hydrochlorothiazide was given when the resident's systolic blood pressure was below the ordered parameter. The Director of Nursing confirmed in an interview that the medications should have been held according to the physician's orders.
Failure to Implement Fall Prevention Measures and Maintain Equipment Safety
Penalty
Summary
The facility failed to implement adequate safety measures for two residents at risk for falls. One resident, who was cognitively intact and required substantial assistance for mobility and transfers, reported falling in the bathroom due to an unstable wheelchair with a broken right brake. The resident stated she had informed several staff members about the malfunction, and observation confirmed the brake was not working. Staff interviews revealed awareness of the issue, but a work order for repair was not placed until after the incident, and facility leadership was not aware of the problem until then. Another resident, also cognitively intact and with a history of multiple fractures and falls, did not have a required sign in her bathroom reminding her to call for assistance, as specified in her care plan. Observations confirmed the absence of the sign on two occasions. The resident's care plan included this intervention due to her high fall risk, but staff indicated the resident frequently removed such signs, believing she did not need help. The facility's fall management policy requires investigation and intervention after falls, but the specified interventions were not consistently implemented.
Failure to Maintain Proper Catheter Bag Position and Accurate Output Documentation
Penalty
Summary
A deficiency was identified when a resident with a history of neuromuscular dysfunction of the bladder, urinary retention, and previous urinary tract infections was observed with an indwelling Foley catheter collection bag resting on the floor under her wheelchair on two separate occasions. The resident was noted to be severely cognitively impaired and had physician orders for an indwelling urinary catheter with catheter care to be performed every shift. The care plan included interventions such as maintaining the catheter bag below the bladder, keeping the leg strap in place, and recording urinary output. Upon review of the resident's records, it was found that documentation of urinary output was not completed as required. Instead of recording the actual volume in milliliters, staff documented output as 'small,' 'medium,' or 'large' on multiple occasions over a two-month period. During an interview, the DON confirmed that the facility did not have a specific policy regarding documentation of urinary output for residents with catheters and had no further information to provide.
Failure to Provide Prescribed Oxygen Flow Rate
Penalty
Summary
A resident with diagnoses including acute respiratory failure with hypoxia and metabolic encephalopathy was observed using portable oxygen in her room, with the flow meter set at 2 liters per minute (LPM). According to the resident's physician order, oxygen was to be administered continuously at 4 LPM by nasal cannula. The resident, who was moderately cognitively impaired and dependent on staff for toileting and transfers, was observed twice with the oxygen set incorrectly at 2 LPM. During the second observation, an LPN acknowledged the error and adjusted the flow rate to the prescribed 4 LPM at that time. This deficiency occurred because the facility failed to ensure the resident received the necessary care and treatment related to the prescribed oxygen flow rate.
Failure to Document Pain Assessment and Non-Pharmacological Interventions Before Administering Pain Medication
Penalty
Summary
The facility failed to ensure that a resident’s pain medication regimen was free from unnecessary drugs by not documenting pain assessments or the use of non-pharmacological interventions prior to administering acetaminophen. A resident with diagnoses including chronic bronchitis, heart failure, anemia, and atrial fibrillation, who required substantial assistance for mobility, received acetaminophen 15 times over an 18-day period. The medication administration records lacked documentation of pain location, severity, or any non-pharmacological interventions attempted before giving the medication, despite the care plan specifying these interventions and documentation. The DON confirmed that pain level, site, and prior interventions should have been documented before administering the pain medication.
Failure to Implement Enhanced Barrier Precautions for Resident on Isolation
Penalty
Summary
The facility failed to implement infection control guidelines for Enhanced Barrier Precautions for a resident who required isolation. Observations on two separate occasions revealed that there were no signs posted on or near the resident's door to indicate Enhanced Barrier Precautions were in place, and there were no personal protective equipment (PPE) bins available near or inside the room. The resident's medical record showed diagnoses including dysphagia and dementia, with documentation indicating severe cognitive impairment and the need for a feeding tube. A physician's order specified that staff should use a gown and gloves during high-contact care activities for this resident, but these precautions were not visibly supported in the environment at the time of surveyor observation.
Delayed Breakfast Service in VIP Dining Room
Penalty
Summary
The facility failed to ensure that meals were served with no more than 14 hours between the evening meal and breakfast the following day, affecting residents in the VIP Dining Room. On the morning of January 21, 2025, breakfast was observed being served to 11 residents in the VIP Dining Room at 10:06 a.m., which was significantly later than the expected time of 8:30 a.m. to 9:00 a.m. The delay was attributed to the CNAs being unable to get all residents to the dining room on time, and the dietary staff waiting until most residents were seated to keep the food warm. The previous evening, dinner was served in the VIP Dining Room between 4:45 p.m. and 5:15 p.m., depending on when the kitchen staff received a call from the CNAs indicating residents were ready to eat. This resulted in more than 14 hours between dinner and breakfast for the residents in the VIP Dining Room. The Director of Food Services and the Director of Nursing were both aware of the situation, with the latter noting that CNAs were already preparing residents for the day when she left the facility early in the morning.
Failure to Address Bathing Refusals in Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident with dementia, who frequently refused bathing, received the necessary bathing services at least twice a week. The resident, who had a preference for showers, indicated she had not been bathed since her admission. The care plan required assistance for activities of daily living (ADLs) and included interventions such as not rushing the resident and offering encouragement. However, the plan did not reflect the resident's behavior of refusing baths. The facility's documentation showed multiple instances of the resident refusing showers, but these refusals were not documented in the progress notes or behavior point of care documentation. The Director of Nursing (DON) and Social Service Director were unaware of the resident's consistent refusals, as the refusals were not communicated or documented properly. The facility's policy required behaviors to be assessed and evaluated, with interventions communicated to the interdisciplinary team, but this process was not followed. The DON conducted random audits but did not identify the issue due to the lack of documentation. The facility's failure to document and address the resident's bathing refusals led to a deficiency in providing appropriate care for the resident's dementia-related behaviors.
Resident Elopement Due to Inadequate Supervision and Alarm Malfunction
Penalty
Summary
The facility failed to provide adequate supervision to a cognitively impaired resident with a history of exit-seeking behavior, resulting in the resident eloping from the facility. The resident, who was wearing a Wanderguard bracelet, managed to exit through an alarmed door that was left open due to a rug obstructing it. The resident was found 0.3 miles away by a Good Samaritan, who called 911. The resident was returned to the facility without injury after being assessed by EMS. The incident occurred when the resident, who had been administered Xanax for anxiety, was left unsupervised between 6:15 p.m. and 6:47 p.m. on the day of the elopement. Staff statements indicated that the resident had been exhibiting exit-seeking behavior earlier in the day, and interventions such as walking with the resident or offering a snack were not documented as being implemented. The door alarm, which should have been triggered by the Wanderguard, was not heard by staff, and the annunciator panel was found to be improperly wired, preventing the alarm from being heard in the Assisted Living Nurses' Station. Interviews with staff revealed a lack of awareness and response to the door alarm. Environmental Services staff adjusted the rug and closed the door without recalling if the alarm was sounding. The facility's policy required prompt response to door alarms, but staff did not follow the procedure to ensure the resident's safety. The facility's failure to ensure the door alarm system was fully functional and to provide adequate supervision contributed to the resident's elopement.
Removal Plan
- The rug in the vestibule was removed.
- All residents in the facility were reviewed for elopement risk.
- The residents who were assessed as an elopement risk have Wanderguard bracelets initiated.
- All Physician's Orders for the bracelets and checking for functioning and placement were reviewed and were up to date.
- All exit doors have been evaluated to ensure the Wanderguard is functioning.
- Elopement binders have been updated.
- 93 of 122 employees have been educated on the elopement/missing resident policy and all remaining staff will be educated upon their return to work.
- An elopement drill was completed without concerns.
Failure to Provide Necessary ADL Care
Penalty
Summary
The facility failed to ensure residents received the necessary care for activities of daily living (ADL) related to long unkempt fingernails and the lack of offering residents shaving per the plan of care. Resident 21 was observed on multiple occasions with long, thickened, and discolored fingernails. Despite the resident expressing a desire to have her nails trimmed, no one had offered to trim them. The resident's care plan indicated she required substantial assistance with personal hygiene due to her medical conditions, including diabetes mellitus, dementia, stroke, and Parkinson's disease. The Director of Nursing (DON) acknowledged that the staff should have attempted to soak and cut her fingernails before the surveyor's observation. Resident 26 was observed with grown-out facial hair and disheveled hair on multiple occasions. His care plan indicated he required staff assistance to complete ADL tasks, including offering facial shaving on shower days or as needed. However, there was no documentation available in the record related to the resident receiving assistance with shaving. The DON indicated that the resident's electric razor had broken, and they were trying to get it replaced but were unable to contact the resident's son. The DON also mentioned that shaving was considered basic care and did not need to be documented in the record.
Failure to Monitor and Assess Skin Discolorations
Penalty
Summary
The facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of skin discolorations for three residents. Resident 38, who had diagnoses including atrial fibrillation and hypertension, was observed with dark purple discolorations on her hands and multiple bandaids over several days. Despite being at risk for excessive bleeding and bruising due to her medications, there was a lack of follow-up on her skin discolorations after an initial event note indicated various stages of healing. Weekly skin assessments did not document any new skin issues, and the Director of Nursing (DON) acknowledged the need to start a skin event for the resident. Resident 4, diagnosed with dementia and pulmonary fibrosis, was observed with a large scabbed area on his right knee. After a fall, a progress note indicated his right knee was red but blanchable, with no further documentation or monitoring of the scabbed area. Weekly skin assessments failed to indicate any new skin issues, and the DON confirmed the lack of further monitoring after the initial fall. Resident 26, with diagnoses including dementia and Parkinson's disease, was observed with discolorations and a small abrasion on his left forearm. Despite a care plan indicating the need for weekly skin assessments and observation during routine caregiving, there was no documentation related to the abrasion and discoloration. The DON mentioned that the resident self-propelled throughout the facility, which likely caused the old abrasion, but could not provide additional information.
Failure to Ensure Proper Wheelchair Positioning for Resident
Penalty
Summary
The facility failed to ensure a resident received the necessary treatment to prevent a decrease in range of motion related to improperly positioned leg rests and a footboard on a wheelchair. Resident 154, who has diagnoses including dementia, anxiety, and a history of falls, was observed in a wheelchair with leg rests and a footboard extended horizontally. The resident repeatedly attempted to place her feet on the floor, but an Activity Aide continually repositioned her feet back onto the leg rests, indicating the resident was at risk of falling if she tried to stand. The Director of Nursing (DON) was unaware of the reason for the leg rests being positioned that way and later found that the resident tried to stand when the leg rests were removed, indicating the leg rests should not have been positioned so high since the resident could propel herself in the wheelchair. The Therapy Director (TD) confirmed that the leg rests and footboard were recommended for positioning and safety but should not have been positioned horizontally. The TD was unaware of recent incidents where the resident almost tipped her chair and turned her wheelchair over in the dining room, indicating a lack of proper documentation on the assistive devices recommended by therapy staff.
Improper G-Tube Placement Check Before Medication Administration
Penalty
Summary
The facility failed to ensure a gastrostomy tube (g-tube) was properly checked for placement prior to medication administration for one resident. During a medication pass observation, an LPN was seen preparing and administering medications to the resident with a g-tube. The LPN checked the g-tube placement using an air bolus instead of removing residual from the g-tube as per the facility's policy. The LPN then proceeded to administer the medications and flushes through the g-tube without following the correct procedure for checking tube placement. During an interview, the LPN acknowledged that the correct procedure was to check for placement by removing residual from the g-tube, not with an air bolus. The Director of Nursing had no further information to provide. The facility's policy indicated that proper tube placement should be checked using air and auscultation only, and that gastric content should be checked for residual feeding, with any residual volumes above 100 ml to be reported.
Improper Medication Storage in Medication Carts
Penalty
Summary
The facility failed to ensure medications were stored appropriately, as evidenced by unidentified and crushed pills found in medication cart drawers for two medication carts. The 100 Hall Medication Cart was observed with multiple unidentified whole pills and crushed medications in the drawer. RN 1 indicated that the night shift staff was responsible for cleaning the medication carts, but this was not done. Similarly, the 300 Hall Medication Cart was found with two unknown whole pills in the drawer. RN 2 also stated that the night shift staff was supposed to clean the carts. The Director of Nursing was informed of the findings but had no further information to provide. The facility's policy on medication storage requires that all medications be stored in labeled containers and that outdated or contaminated medications be immediately removed and disposed of properly.
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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 Lowell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lowell Healthcare | 0.9 mi | — | 21 | 0 |
| Ignite Medical Resort Crown Point Llc | 6.5 mi | — | 37 | 0 |
| Saint Anthony | 7 mi | — | 3 | 0 |
| Colonial Nursing Home | 8.5 mi | — | 0 | 0 |
| Crown Point Health Campus | 10.4 mi | — | 23 | 0 |
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