Nursing Home News — Page 491

The February 21 inspection found staff weren't monitoring visits involving residents with open Adult Protective Services cases.

Staff found redness on the victim's face.

The January 29 complaint inspection revealed systemic breakdowns in safety protocols that put residents at immediate risk.

The resident, who has severe cognitive impairment and depends on kidney dialysis, was also taking three other blood pressure medications.

The maintenance department told kitchen staff the steam table couldn't be repaired and would need replacement, but no timeline was provided.

Resident 2 had been admitted to Cedarwood Rehabilitation & Healthcare Center on April 4, just days after hip fracture surgery from a fall at home.

Federal inspectors found the facility failed to ensure staff called for help when residents showed signs of distress.

Federal inspectors documented response times that stretched far beyond what the facility's own administrator considered acceptable.

The crisis began when water samples taken in late 2024 revealed Legionella bacteria in seven of 10 locations throughout the building.

The compression system is designed for venous leg ulcers and lymphedema, not diabetic wounds.

The nurse later admitted she called out the roommate's name and gave the medications to the wrong woman when she responded.

## Widespread Food Safety Deficiencies Documented The January 29, 2026 inspection revealed systematic problems with the facility's food handling operations.