Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 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 Health And Rehabilitation during CMS and state inspections, most recent first.
Several residents with cognitive and physical impairments experienced repeated falls or accidents without consistent updates to their care plans or effective implementation of interventions. Staff interviews and observations revealed lapses in supervision, delayed response to call lights, and inconsistent use of safety devices such as alarms, low beds, and non-slip footwear. Despite documentation of falls and injuries, care plans were not always revised, and staff were sometimes unaware of required interventions.
Several residents reported that meals were often cold, bland, and overly processed, leading some to skip meals. Observations confirmed that food was served at lukewarm temperatures and lacked seasoning, despite the use of plate warmers and pre-service temperature checks. The process of meal delivery resulted in significant delays, contributing to the deficiency in providing appetizing and properly tempered food.
A resident with hypertension and chronic kidney disease did not receive a scheduled morning dose of Metoprolol because the medication was out of stock. An LPN confirmed the medication was unavailable and would not be delivered until later in the day. The facility's process for reordering medications, which relies on visual cues from blister packs, failed to prevent the stockout, and there was no emergency supply available. Required documentation and MD notification for the missed dose were also not completed.
Failure to Prevent Accidents and Update Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that the environment was as free from accident hazards as possible and did not provide adequate supervision and assistance devices to prevent accidents for five residents. Multiple residents experienced repeated falls or accidents without consistent or effective updates to their care plans or interventions. For example, one resident with Alzheimer's disease and a history of falls experienced several falls, some resulting in injury, while wandering unsupervised or attempting to get out of bed. Despite these incidents, care plan interventions were not always updated after each fall, and staff interviews revealed inconsistent use of alarms and supervision. Observations also showed that staff were not always present to assist the resident, and family members reported delayed staff response to call lights. Another resident with a traumatic brain injury, right-sided weakness, and poor safety awareness experienced multiple falls, including incidents in the bathroom and during transfers. The care plan for this resident was not consistently updated with new interventions after each fall, and some interventions, such as the use of a knee brace or non-slip footwear, were not always implemented. Staff interviews indicated that there was confusion or lack of awareness regarding specific interventions, and observations revealed that the resident's bed was not always kept in the lowest position and that appropriate footwear was not always used. The facility's QAPI documentation acknowledged an increase in falls and identified issues with implementing interventions, but falls with injuries continued to occur. A third resident, who was cognitively intact but had a history of falls and a recent fracture, also experienced falls without new interventions being added to the care plan. After a fall resulting in a tibial plateau fracture, the resident continued to use a wheelchair, but the care plan did not reflect any new strategies to prevent further incidents. Documentation showed that education on using the call light was provided, but this intervention had been in place for years and was not newly implemented in response to the recent falls. Overall, the facility did not consistently update care plans or implement new interventions after repeated accidents, and staff were not always aware of or following existing interventions.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and served at an appetizing temperature for five residents. Multiple residents reported receiving cold food, with one resident specifically mentioning a cold hamburger that tasted artificial and another stating that food was often not served warm. Residents also described the food as bland, with one noting that seasonings such as Mrs. Dash were requested in resident council meetings due to widespread salt restrictions. Some residents expressed dissatisfaction with the processed nature of the food, leading them to skip certain meals entirely. Observations during meal service revealed that food temperatures were below recommended levels when served, with items such as grilled chicken sandwiches and tater tots being lukewarm and peas lacking seasoning. The process for meal delivery involved serving residents in their rooms first, followed by those in the dining room, with significant time lapses between when food left the kitchen and when it was served. Although the cook used a plate warmer and took food temperatures before service, the food was not consistently maintained at appropriate temperatures by the time it reached residents. The Dietary Manager acknowledged receiving feedback about food temperature and quality through various channels, including resident council and staff communication.
Missed Dose of Antihypertensive Due to Medication Out of Stock
Penalty
Summary
A deficiency occurred when a resident with essential hypertension and chronic kidney disease stage 3 did not receive her scheduled morning dose of Metoprolol due to the medication being out of stock. Observation during morning medication administration revealed that the LPN was unable to administer the medication, and confirmed with the pharmacy that it would not be delivered until later that day. The resident's medication order required Metoprolol to be given twice daily, with the morning dose scheduled between 7:00 AM and 9:00 AM. The medication had last been ordered over two weeks prior, and there was no emergency supply available in the facility. Interviews with nursing staff and the DON indicated that the facility's process for reordering medications relied on visual cues from the medication blister pack, specifically when only the blue-marked section remained, which should trigger a reorder approximately eight days before running out. Despite this system, the medication was not reordered in time, resulting in a missed dose. Additionally, there was no documentation in the resident's progress notes regarding the missed dose or notification to the MD, as would be expected per facility protocol.
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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 Cedar City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonehenge Of Cedar City | 0.1 mi | — | 4 | 0 |
| Garfield County Nursing Home | 26.7 mi | — | 0 | 0 |
| Hurricane Health And Rehabilitation | 37.6 mi | — | 7 | 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.