The Woods at Cedar Run.

“Mouse feces were observed on the floor and on various food items in the main kitchen's pantry, including on 2 bags of powdered sugar and on canned foods. One bag of powdered sugar had a hole chewed through it.”

“There was an unlabeled and undated pan of lasagna in the main kitchen refrigerator.”

“There was a full, uncovered and unattended trash can in the main kitchen.”

“There were 3 uncovered small plates of applesauce stored in the main kitchen refrigerator.”

“A frozen bag of hamburger buns was stored on the floor in the walk-in freezer.”

“Resident #5 did not receive prescribed Hydrocodone on 4/11/25 at 8:00 PM because the medication was not available in the home.”

“A waiver for a staff member's non-US education that was approved on 4/14/14 was not publicly and conspicuously posted in the home as required.”

“Inappropriate text messages were found between resident #1 and staff person A, including staff person A sending naked pictures to resident #1. This constitutes abuse and mistreatment of the resident.”

“An uncovered bedside mobility device with an opening measuring 13 inches by 22 inches was installed on the left side of resident #2's bed, posing a potential limb or head entrapment risk.”

“A Debrox earwax removal kit, a tube of maximum strength Hydrocortisone Cream 1%, and a tube of Polysporin Bacitracin Zinc were unlocked, unattended, and accessible in resident #2's bathroom cabinet. Resident #2 is not assessed as being able to self-administer these medications.”

“A chair blocked egress from the sunroom in the secured dementia care unit to the gated courtyard. A bench and a metal trashcan blocked egress from the gated courtyard to the back of the home.”

“Alleged abuse of a resident by Staff Member A was reported to Staff Member B via telephone call from resident's family member on 10/25/24. Staff Member B relayed this information to Staff Member C via email the same day. However, this allegation of abuse was never reported to the Adult Abuse Alert System (AAA) as required by the Older Adult Protective Services Act.”

“A resident fell in the home, hit their head, and was unable to move on the ground. The resident was sent to the hospital and diagnosed with a broken clavicle. The home did not report this incident to the Department within 24 hours as required.”

“On a specific date at 9:29AM, Resident's record information including medication orders, medical appointments, assessment and care plans were unlocked, unattended, and accessible on the computer on the medication cart in the secure unit.”

“The home's current licensing inspection summaries dated 2/1/24 and 4/4/23 were not posted in a conspicuous and public place in the home.”

“Direct Care Staff Member A attended a non-U.S. educational institution and provides assistance with ADLs. The home did not have a Department-issued waiver for the staff member's employment.”

“From 11:00 PM on 6/2/24 until 6:30 AM on 6/3/24, fifty-five residents were present in the home with only one staff member present with current CPR and first aid certification, violating the requirement of at least one trained staff person for every 50 residents. This was a repeated violation.”

“The bed located in resident #236 had an uncovered enabler device with an opening measuring 11.5 inches in width and more than 4 3/4 inches in height, posing a potential risk of entrapment. This was a repeated violation.”

“Three drawers in the Third Floor East medication cart were observed to contain dirt, dust, loose strands of hair and trash particles, creating unsanitary storing conditions for medications and disposable medication cups.”

“The bathroom ventilation fan in resident room #112 was inoperable when the switch was activated, and the bathroom had no outside window.”

“Prescription medications and syringes were found unlocked, unattended, and accessible on top of medication carts on the 2 East and 2 West units.”

“Multiple expired and loose medications were found improperly stored in medication carts on 2 East, 2 West, 3 East, and Memory Care units, not maintained under proper conditions or in accordance with manufacturer's instructions.”