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 Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility’s activities program was directed by an Activity Director (AD) who did not meet required qualifications. The AD had been in the role for several months without being enrolled in an activities director course and was not certified, despite the facility’s job description requiring a certified AD with appropriate state-required credentials. Interviews with the AD and the Administrator, along with personnel record review, confirmed that the AD lacked the necessary certification and training, potentially affecting the provision of individualized activities for residents.
Surveyors found that kitchen sanitation and staff hair restraint practices did not meet professional standards. Bottom shelves holding dishes, pots, and pans were soiled with food crumbs and dust, the stove and oven had grease and dried food buildup, the vent hood was dusty, and pantry shelving and a freezer bottom shelf were dirty with crumbs and debris. During food preparation, the Dietary Manager’s hair net did not fully cover her hair, and another dietary staff member had hair protruding from the back of a hair net. The Dietary Manager and Administrator acknowledged expectations for proper hair coverage and routine cleaning, and facility policy required effective hair restraints and cleaning/sanitizing of kitchenware and food-contact items after each meal.
Surveyors identified that the facility failed to properly implement its infection prevention and control program when an LVN did not disinfect a glucometer between blood glucose testing for a resident and reported using tissue and hand sanitizer instead of the required germicidal/bleach wipes, contrary to facility policy and DON expectations. In a separate observation, two CNAs provided incontinent and urinary catheter care to a resident with a neurogenic bladder and an indwelling catheter who was on Enhanced Barrier Precautions, but they wore only gloves and omitted gowns despite posted EBP signage and care plan instructions requiring gown and glove use for high-contact care. Both CNAs later acknowledged they had forgotten to wear gowns, and leadership confirmed staff were trained and expected to use appropriate PPE and that failure to do so could lead to infections and cross contamination.
Surveyors found that all reviewed dual-occupancy rooms used a single ceiling-to-floor curtain that divided the room but did not extend around each bed or fully cover the area near the door, resulting in a lack of full visual privacy for residents. The DON acknowledged being unaware that the curtains did not provide full visual privacy and noted that residents could be exposed during care if the door was not closed. The Administrator also recognized the possibility of resident exposure during care and reported that the facility had no policy addressing full visual privacy curtains.
The facility failed to maintain a safe and sanitary environment when an industrial-sized garbage dumpster at the back of the building was observed placed directly on a dirt surface instead of on a concrete slab. During the survey, it was also determined that the facility lacked a policy addressing dumpster placement and management, contributing to this environmental sanitation deficiency.
Numerous missing and damaged ceiling tiles in Hall 3 were left unrepaired after air conditioning work, exposing electrical wires and air ducting. A resident expressed dissatisfaction with the prolonged disrepair, and both the Maintenance Director and Administrator acknowledged the need for replacement.
The facility did not post up-to-date nurse staffing information in a prominent location for 12 consecutive days. The ADON, responsible for posting, stated she had been busy with other duties and forgot to update the information, and the Administrator was unaware the postings were not current. Facility policy requires daily posting of nurse staffing details for residents and visitors.
A resident with multiple health conditions and a high fall risk experienced an unwitnessed fall after attempting to toilet herself. Despite a completed fall risk assessment and increased monitoring initiated by staff, the care plan was not updated to include new interventions. Staff relied on verbal communication rather than reviewing or revising the care plan, and the DON was unaware of the lack of updates.
A facility failed to maintain an effective infection control program when the DON and an RN did not follow Enhanced Barrier Precautions (EBP) during wound care for a resident with a history of acute osteomyelitis and other health conditions. Despite the resident's care plan requiring EBP, both staff members neglected to wear gowns, citing busyness and oversight. This failure to adhere to the facility's EBP policy could lead to cross-contamination and infection.
The facility failed to maintain resident dignity by serving meals on trays in a manner deemed institutional-like and allowed staff to use personal cell phones during care, making residents feel ignored. Observations and resident interviews confirmed these practices, which violated the facility's policy on personal communication devices.
A facility failed to maintain an effective Infection Prevention and Control Program during wound care for a resident with a chronic ulcer. RN B did not adhere to proper hand hygiene protocols, failing to change gloves and perform hand hygiene at critical points. The nurse also did not clean the bedside table or use a barrier before placing supplies, and did not clean the wound care spray bottle after use. The DON and Administrator acknowledged the importance of proper technique, but the facility's policy was not followed.
The facility failed to prepare 33 resident rooms in B Building for occupancy, as they were used for storage and required cleaning and repairs. These rooms, identified as Title 18 Medicare-Only and dually certified beds, had not been used since 2020. Interviews revealed that the rooms could not be made livable quickly, and the corporate plan to remodel the building was not prioritized due to low census. The facility lacked a policy on bed classification, and the corporation did not want to declassify the rooms due to recertification costs.
Unqualified Activity Director Leading the Activities Program
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional, as the current Activity Director (AD) did not meet the required qualifications. During an interview, the AD reported she had been working in the role since April 2025 and was not registered for an activities director course. She stated that a previous administration had told her they would assist her with getting registered for an AD course, but after that administration left, she did not get enrolled. Record review confirmed the AD was neither enrolled in an activity course nor certified as an AD. The facility’s job description for the Activity Director, dated 2014, specified that the position required a high school graduate with certification where required by state regulations and that the individual must be a certified Activity Director. The report stated this failure could place residents at risk for reduced quality of life due to lack of individualized activities that matched their skills, abilities, and interests/preferences. The Administrator acknowledged in an interview that the AD was not yet enrolled in the required AD course and confirmed they were working on getting her enrolled, further supporting that the AD did not currently meet the stated qualification requirements.
Food Service Sanitation and Hair Restraint Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper food storage, preparation, distribution, and service practices that did not meet professional standards. During an initial kitchen tour, they observed that bottom shelves throughout the kitchen, including those holding dishes, pots, and pans, were soiled with food crumbs and dust. The stove and oven were soiled with grease, food crumbs, and dried food, and the vent hood was covered with a layer of dust. In the pantry, the bottom shelf of the freezer was soiled with food crumbs and frozen foods, and a shelf with plastic covering was noted to have a layer of dust and food crumbs. These observations were reviewed with the Dietary Manager, who acknowledged the presence of food crumbs, dirt, and dust on these surfaces. In a follow-up observation during food preparation, the Dietary Manager’s hair net covered only the bun or top part of her hair, and another dietary staff member had hair coming out of the back of her hair net. In an interview, the Dietary Manager stated that hair nets should cover all hair, explained that her hair net sometimes rolled up without her noticing, and admitted she had not noticed the other staff member’s hair hanging out of the hair net. The Administrator later stated that his expectation was for staff to wear hair nets correctly and for the kitchen, including the stove, oven, freezer, appliances, and vent hood, to be cleaned routinely. Review of the facility’s Infection Control policy showed that clean hair was required to be covered with an effective hair restraint and that all kitchenware and food contact items used in preparation or serving of food were to be cleaned and sanitized before use and cleaned after each meal preparation.
Failure to Disinfect Glucometer and Adhere to Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program related to glucometer disinfection and use of personal protective equipment (PPE) during care of a resident on Enhanced Barrier Precautions (EBP). During observation, an LVN obtained a fasting blood sugar from Resident #21 by taking a small blood sample from the resident’s finger and applying it to a test strip in a glucometer. After completing the blood sugar test, the LVN exited the room and placed the glucometer on the cart without sanitizing it. In interview, the LVN stated she used a tissue and hand sanitizer to sanitize the glucometer and reported she was unaware of what she was supposed to use to sanitize it. The DON stated that glucometers were supposed to be cleaned using bleach wipes, that nurses were trained upon hire and annually on proper disinfection of glucometers, and that the risk of not using the proper solution for sanitizing glucometers was passing on infections. Facility policy for glucometers required the meter to be cleaned with a germicidal and allowed to air dry between patient testings. The deficiency also involves failure to follow EBP requirements for a resident with an indwelling urinary catheter. Resident #3 was admitted with neuromuscular dysfunction of the bladder and muscle weakness and had an indwelling catheter for neurogenic bladder. The resident’s care plan documented that she was on EBP, with an expectation that there would be no signs and symptoms of urinary infection and no transmission of infection from or to the resident. The care plan specified that gloves and gown should be donned for high-contact activities including linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. The MDS assessment also indicated the presence of an indwelling catheter. During observation, two CNAs entered Resident #3’s room to perform incontinent care. Both staff washed their hands and put on gloves but did not don gowns despite an EBP posting outside the room. They removed the resident’s brief, cleansed the vaginal area and urinary catheter tubing with wet wipes, turned the resident to her side, cleansed the rectal area where a bowel movement was present, repositioned the urinary catheter on the bed, and applied a new brief. In interviews, both CNAs acknowledged that the EBP posting indicated they were supposed to use PPE such as gloves and a gown when providing personal care for a resident with a urinary catheter, stated they had forgotten to wear a gown, and agreed they should have worn a gown along with gloves. The ADON stated staff were expected to wear EBP when providing care for residents with a urinary catheter and that the CNAs had been trained and were aware they had to wear PPE but had forgotten. The DON and Administrator both stated that failure to wear PPE as indicated could lead to infections or cross contamination. The facility’s Enhanced Barrier Precautions policy stated that EBP is indicated for residents with wounds and/or indwelling medical devices, including urinary catheters, and involves targeted gown and glove use during high-contact resident care activities.
Failure to Provide Full Visual Privacy in Dual-Occupancy Rooms
Penalty
Summary
Surveyors identified that dual-occupancy rooms in the facility were not designed or equipped to assure full visual privacy for residents. Observation of rooms 301, 303, 306, 307, 309, and 310 showed each contained an A and B bed separated only by a single ceiling-to-floor curtain that divided the center of the room but stopped approximately 24 inches from the door, and the curtains did not extend around the entire beds to provide full coverage and privacy. These observations demonstrated that the rooms lacked ceiling-suspended curtains that extended around each bed to provide total visual privacy. During interview, the DON stated she was unaware that the existing curtains failed to provide full visual privacy and acknowledged there was a possibility of residents being exposed during resident care if the door was not closed. In a separate interview, the Administrator similarly acknowledged that if there was no full visual privacy in the resident rooms, there was a possibility of residents being exposed during resident care, and further stated that the facility did not have a policy on full visual privacy curtains.
Improper Placement of Industrial Dumpster on Dirt Surface
Penalty
Summary
The facility failed to provide a safe and sanitary environment by not properly situating its industrial-sized garbage dumpster. On observation, the dumpster was located at the back of the facility on a dirt surface rather than on a concrete slab. The dumpster placement was noted during a surveyor observation, and it was also identified that the facility did not have a policy governing dumpster placement or management. This deficiency pertains to the facility’s responsibility to maintain a safe, easy-to-use, clean, and comfortable environment for residents, staff, and the public. No specific residents, their medical histories, or conditions at the time of the deficiency were mentioned in the report.
Failure to Replace Damaged and Missing Ceiling Tiles in Hall 3
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents in Hall 3 by not replacing missing and damaged ceiling tiles. Observations revealed that numerous ceiling tiles were either missing or damaged, leaving electrical wires and air ducting exposed. This condition was directly observed during a facility walkthrough and was confirmed through interviews with both a resident and facility staff. A resident reported that the ceiling tiles in Hall 3 had been in disrepair for an extended period, expressing dissatisfaction with the appearance and upkeep of the area. The Maintenance Director acknowledged that the tiles had been removed during recent air conditioning work, which had been completed weeks prior, but the tiles had not yet been replaced. The Administrator also confirmed that the ceiling tiles in Hall 3 were in need of replacement.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a prominent and accessible location for residents and visitors over a 12-day period. Observations on 08/20/25 revealed that the staffing information posted outside the Administrator's door was outdated, displaying the date 08/08/25. Interviews with the Administrator and the ADON confirmed that the daily staffing information had not been updated or posted for 12 consecutive days. The ADON, who was responsible for posting the information, stated that she had been busy with other job duties and had forgotten to keep the posting current. A review of the facility's policy, dated 01/01/2024, indicated that nurse staffing information should be made readily available in a readable format to residents and visitors at all times, with the staffing sheet posted daily. The Administrator acknowledged that she was unaware the postings were not current and reiterated that it was the ADON's responsibility to maintain the daily postings. No information was provided regarding any specific residents affected or their medical conditions at the time of the deficiency.
Failure to Update Care Plan After Fall Assessment
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident after a fall risk assessment was completed. The resident, an elderly female with multiple diagnoses including muscle wasting, dementia with agitation, anxiety disorder, gait abnormalities, and cachexia, was identified as high risk for falls. Despite a fall risk assessment indicating a high-risk score and an unwitnessed fall occurring in the resident's room while attempting to toilet herself, the care plan was not updated to reflect new interventions following the incident. The last documented update to the care plan was prior to the fall, and no new interventions were added after the assessment on the date of the fall. Interviews with nursing staff revealed that updates and interventions were communicated verbally and through 24-hour reports, rather than by reviewing or updating the care plan. Both the RN and CNA involved in the resident's care confirmed that they did not review care plans for updates, relying instead on verbal communication. The interim DON was unaware that the care plan had not been updated after the fall, and facility policy required that individual plans of care be implemented after each fall risk assessment.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of the Director of Nursing (DON) and a registered nurse (RN A) who did not adhere to Enhanced Barrier Precautions (EBP) during wound care for a resident. The resident, a cognitively intact male with a history of acute osteomyelitis, type II diabetes, and other health conditions, was admitted to the facility with a care plan that included EBP. Despite this, during an observation, both the DON and RN A neglected to wear gowns while providing wound care, which is a requirement under the facility's EBP policy. Interviews with the DON and RN A revealed that they were aware of the EBP requirements but failed to comply due to being busy and not thinking about it at the time. The facility's policy on EBP clearly states that gowns and gloves should be worn during high-contact resident care activities to prevent the transfer of multidrug-resistant organisms. This oversight in following established procedures could potentially lead to cross-contamination and infection among residents.
Failure to Maintain Resident Dignity and Staff Cell Phone Use
Penalty
Summary
The facility failed to treat residents with respect and dignity, particularly during meal times and in the use of personal communication devices by staff. During an observation of the female locked unit's lunch meal, it was noted that meals were served on trays, which was different from the main dining room where meals were placed directly on the table. This practice was identified as institutional-like and not conducive to promoting a dignified existence for the residents. The Director of Nursing (DON) acknowledged the difference and questioned if it was a dignity issue, while a Certified Nursing Assistant (CNA) remarked that eating off a tray was reminiscent of high school, indicating a lack of consideration for the residents' dignity. Additionally, the facility failed to ensure that staff refrained from using personal cell phones while providing care, which was reported by residents during a confidential group interview. Residents expressed that staff were frequently on their phones during various care activities, including medication administration and dining room duties, making them feel ignored and isolated. Observations confirmed staff using phones while setting up smoking materials and the Activity Director using a phone in the dining room. The facility's Personnel Handbook prohibits the use of personal communication devices during work hours, except for designated personnel, yet this policy was not adhered to, contributing to the residents' diminished quality of life.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the improper wound care provided to Resident #15. The resident, a male with a chronic ulcer on his left foot, was admitted with a diagnosis of a non-pressure chronic ulcer. During a wound care procedure, RN B did not adhere to proper hand hygiene protocols, which is crucial in preventing cross-contamination and infection. Specifically, RN B failed to change gloves and perform hand hygiene at several critical points during the wound care process. RN B initially donned gloves and personal protective equipment (PPE) but did not clean the bedside table or use a barrier before placing wound care supplies. After removing gloves, RN B did not perform hand hygiene before donning new gloves to handle the resident's wound. The nurse repeatedly wiped the wound with the same gauze and failed to perform hand hygiene between glove changes. Additionally, RN B did not clean the wound care spray bottle after use, which could contribute to contamination. The Director of Nursing (DON) and the Administrator both acknowledged the importance of proper hand hygiene and aseptic technique during wound care. The DON noted that wiping the wound multiple times with the same gauze could re-contaminate the wound. Despite RN B's attendance at infection control in-services, the facility's policy and procedure for wound care were not followed, leading to a deficiency in the infection control program.
Facility Fails to Prepare Resident Rooms for Occupancy
Penalty
Summary
The facility failed to ensure that 33 out of 85 resident rooms were equipped for adequate nursing care, comfort, and privacy. These rooms, located in B Building, were not resident ready and had not been used for residents since 2020. The facility had identified certain rooms as Title 18 Medicare-Only beds and others as dually certified (Title 18/19) beds, but these rooms were not prepared for resident occupancy. The deficiency was identified through observation, interviews, and record review, revealing that the rooms were being used for storage and required deep cleaning and cosmetic repairs. Interviews with the Corporate Compliance RN and the Administrator confirmed that the rooms could not be made livable within a reasonable timeframe. The Administrator stated that the building had been used for storage since before her tenure began in 2023, and the corporate plan to remodel the building for a rehabilitation unit had not been prioritized due to low census. Despite the rooms being functional, they were not suitable for residents without thorough cleaning and repairs. The facility lacked a policy regarding bed classification, and the corporation was reluctant to declassify the rooms due to the cost of recertification.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Park Plaza Nursing And Rehabilitation Center | 0.6 mi | — | 0 | 0 |
| Sagecrest Alzheimers Care Center | 2.4 mi | — | 0 | 0 |
| Avir At Arbor Terrace | 3.1 mi | — | 7 | 0 |
| Avir At Meadow Creek | 3.9 mi | — | 1 | 0 |
| St. Juanita Retirement And Rehab | 4 mi | — | 3 | 0 |
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