Inspection Reports for
Cedar Health and Rehabilitation
411 West 1325 North, Cedar City, UT, 84721
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 3
Date: Jun 26, 2025
Visit Reason
The inspection was an unannounced routine regulatory compliance visit conducted to assess the facility's adherence to state nursing care facility regulations.
Findings
The facility was found compliant with most regulatory requirements, including resident rights, care planning, medication management, and safety protocols. Some minor noncompliance was noted related to comprehensive care plan development and dietary services.
Deficiencies (3)
R432-150-12(4) The licensee failed to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet medical, nursing, and psychosocial needs as identified in the comprehensive assessment.
R432-150-12(5) The licensee did not ensure the comprehensive care plan was developed within seven days after completion of the comprehensive assessment and periodically reviewed and revised by a qualified team.
R432-150-22(1) The licensee failed to provide each resident with a safe, palatable, well-balanced diet that meets daily nutritional and special dietary needs.
Report Facts
Number of rule noncompliances: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Bolander | Licensor | Conducted the inspection |
| Amy Williams | Licensor | Conducted the inspection |
| Nicole Kololli | Licensor | Conducted the inspection |
| Catherine Bristow | Licensor | Conducted the inspection |
| Tiffany Stone | Licensor | Conducted the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jul 13, 2023
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving multiple residents at Cedar Health and Rehabilitation.
Complaint Details
The complaint investigation was substantiated as the facility failed to timely report multiple abuse allegations and falls resulting in fractures, failed to thoroughly investigate incidents, and failed to coordinate PASARR assessments. Specific residents identified included #9, 15, 25, 43, 46, and 124.
Findings
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately within required timeframes. Several residents experienced falls resulting in fractures that were not reported to the State Survey Agency within 2 hours as required. The facility also failed to thoroughly investigate multiple falls and abuse allegations and did not coordinate assessments with the PASARR program for residents with serious mental illness.
Deficiencies (8)
F609: The facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, including injuries of unknown source, within 2 hours as required by regulation.
F610: The facility failed to thoroughly investigate all allegations of abuse, neglect, exploitation, or mistreatment and did not report investigations to the State Survey Agency within 5 working days as required.
F644: The facility did not coordinate assessments with the PASARR program for residents with serious mental illness, including failure to refer a resident for a PASARR Level II evaluation after diagnosis.
F676: The facility failed to provide necessary care and services to maintain or improve residents' abilities in activities of daily living, including hygiene, mobility, elimination, dining, and communication for a resident.
F677: The facility failed to provide necessary nail care for a resident, resulting in long fingernails with brown and black substances and lack of documentation of nail care.
F761: The facility failed to label and store drugs and biologicals properly, including insulin pens without expiration dates and open vials without resident identifiers.
F779: The facility failed to maintain complete and accurate clinical records, including missing signed radiology reports and x-rays not located in the medical record.
F812: The facility failed to maintain food safety requirements, including unclean dishwashing areas, food stored improperly, and food items not dated or discarded as required.
Report Facts
Sample residents reviewed: 30
Residents with falls not reported timely: 6
Residents with PASARR coordination issues: 1
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