Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on observation, interview, and record review the facility failed to treat each resident with respect and
dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life
for 1 of 2 meals reviewed for resident rights and for 10 of 10 residents in the confidential group interview.
The facility failed to serve residents in the female secure unit in a manner that was not institutional-like and
serve residents on trays.
The facility failed to ensure staff provided care to residents while not on their cell phones causing residents
to feel left out.
This failure could place residents at risk for decreased meal satisfaction and could result in a diminished
quality of life for the identified residents and could affect additional residents by causing a loss of
self-esteem and increased isolation.
The findings included:
Observation on 12/10/24 at 12:17 p.m. of the female locked unit lunch meal revealed the lunch meal arrived
on a lunch cart. There were six residents present in the dining room. The staff present took the meal off the
cart, checked the card and brought the meal to the resident. The staff placed the meal on the tray in front of
all six residents in the dining room. Comparison to the main dining room on 12/10/24 at 12:24 p.m. of the
main dining room revealed all residents in the main dining room had their food placed on the table.
Interview on 12/10/24 at 12:26 p.m. the DON observed the residents eating in the main dining room and
then compared it to the female residents in the secured unit. She stated she could not identify a difference
since the food was the same and the staff was sitting. The DON stated she did not eat off a tray at home
then asked if it was a dignity issue. CNA A stated the last time she ate off a tray that was not fast-food was
probably high school.
Observation on 12/10/24 at 4:28 p.m. revealed staff setting up smoking materials while texting. Residents
were present at the time of the texting.
During the confidential resident council meeting on 12/11/24 10 alert residents stated staff were on the cell
phones while providing care. The residents stated it did not matter what shift it was, and it did not make a
difference what kind of care the staff was providing. One resident stated staff were on the phone while
passing medications. Other residents stated staff were on the phone while in
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
676068
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676068
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Manor Nursing and Rehabilitation Center
1915 Greenwood St
San Angelo, TX 76901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
the dining room or doing transfers. The resident stated it made them feel left out and not there.
Level of Harm - Minimal harm
or potential for actual harm
Observation on 12/11/24 at 10:32 a.m. revealed the Activity Director cutting through the dining room on her
phone with residents present.
Residents Affected - Some
Review of the Resident Council Minutes, dated 10/16/24, revealed the residents' reported staff were on
their cell phones.
Review of the Resident Council Minutes, dated 11/20/24, revealed the residents' reported staff were on
their cell phones.
Review of the facility's Personnel Handbook dated 2015, on Personal Communication Devices, revealed:
use of personal communication devices during scheduled work hours is not permitted at the facility. These
devices include but are not limited to cell phones and laptop computers. You may only use your personal
communication devices during scheduled lunch/ break times. Communication devices issued by the
facility/company are permitted as they are tools of the job and are to be used accordingly. Employees may
not bring any forms of audio entertainment devices into the facility.
This provision does not apply to designated facility personnel who must use such devices in connection
with their positions of employment. For the designated employees that are required to use such devices in
connection with their position of employment. For the designated employees that required to use their cell
phones in the course of business, the phone may NOT be used in the resident area or used in an
unprofessional manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676068
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676068
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Manor Nursing and Rehabilitation Center
1915 Greenwood St
San Angelo, TX 76901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based
observations, interviews, and record review, the facility failed to maintain an Infection Prevention and
Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the
development and transmission of communicable diseases and infections for one of one (Resident #15)
residents reviewed for wound care.
Residents Affected - Few
The facility failed to ensure that RN B changed her gloves and performed hand hygiene while providing
wound care to Resident #15.
This failure could place the residents at risk of cross-contamination and development of infections.
Findings included:
Review of Resident #15's admission Record, dated 12/12/24, revealed he was an [AGE] year-old male
admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer or the left foot.
Review of Resident #15's Quarterly MDS Assessment, dated 12/9/24, revealed:
Resident # 2? had a mental status exam score of 3 of 15 (indicating severe cognitive impairment)
He had 1 venous or arterial ulcer present.
Review of Resident #15's Care Plan, initiated 10/18/24, revealed:
Focus: The Resident has Venous/Stasis Ulcer related to decreased circulation - ulcer to left 2nd toe.
Goal: the resident's ulcer will be healed by review date.
Interventions: Document location of wound, amount of drainage, peri-wound (surrounding) area, pain,
edema (swelling), and circumference measurements weekly. Evaluate wound for: size, depth, margins
(edges). Document progress in wound healing on an ongoing basis, notify physician as indicated.
Review of Resident #15's Order Summary, dated 12/12/24, revealed orders dated 11/16/24 Clean venous
ulcer to top of 2nd toe of left (foot) with wound cleanser and apply a dry dressing daily and as needed until
resolved every day shift.
Observation and interview on 12/12/24 at 11:39 a.m. RN B stated Resident #15's orders were to clean, dry
and cover with a dressing. RN B opened the cart, gelled her hands with ABHG, donned gloves (put on),
and donned PPE. RN B closed the drawer to the cart. RN B pulled out the treatment supplies of wound
cleanser spray, a bandage and gauze. RN B took off her gloves washed her hands and returned to the cart.
RN B looked around realized she did not clean the bed side table or put a barrier down. RN B donned
gloves, cleaned the bed side table and placed wax paper down. RN B brought her wound-care supplies in
and placed it on the wax paper. RN B took off her gloves, used ABHG and donned new gloves prior to
taking off Resident #15's bandage. Without using any type of hand hygiene. RN B donned
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676068
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676068
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Manor Nursing and Rehabilitation Center
1915 Greenwood St
San Angelo, TX 76901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
new gloves, sprayed Resident #15's toe with wound cleanser and wiped the wound from top to bottom 21
times. RN B took off her gloves, did not use any kind of hand hygiene, and donned a new pair of gloves. RN
B wiped the dry gauze across Resident #15's wound 10 times. RN B held the used (dirty) gauze in one
hand, took off that glove with the gauze inside of it, and threw away the one glove. With no hand hygiene for
the one hand RN B donned a new glove and placed the bandage on Resident #15's toe. RN B changed
both gloves, with no hand hygiene and applied lotion to Resident #15's legs. RN B then put the wound
cleanser back onto the cart without cleaning it while throwing all other equipment away in a bio-hazard bag.
Interview on 12/12/24 at 11:58 a.m. RN B stated she told Resident #15 what she was going to do, gelled
her hands, cleaned off the table, laid out her supplies, washed her hands, then reapplied gel. She stated
she cleaned the wound well by spraying the wound with wound cleanser and covered it with the bandage,
threw everything in a bag and washed her hands. RN B stated she changed her gloves and used alcohol
between glove changes on each step.
Follow up interview on 12/12/24 at 2:38 p.m. RN B stated when the wound care spray was brought into the
room it was considered dirty and she probably did not remember to clean it. RN B stated Resident #15's
wound was so small she did not think anything would be accomplished if she did or did not go over the
wound repeatedly with the same gauze because there was not any infection to spread.
Interview on 12/12/24 at 3:17 p.m. the DON stated her perfect wound care would be for staff to wash their
hands, set up a barrier station, get a red bag for biohazard, wash their hands, don glove, remove the soiled
dressing, doff gloves, use gel, don new gloves, clean the wound from cleanest to dirtiest, take off gloves,
gel, don new gloves, apply the new dressing, take off the gloves and make sure everything went into the
red bag. The DON stated by wiping the wound multiple times it re-contaminated the wound. The DON said
everyone had wound-care check offs with their annual evaluations, including RN B but she could not
remember exactly when RN B's evaluation was. The DON said she did in-services on all thing's infection
control including wound care and hand hygiene in July 2024. The DON stated RN B did attend the
in-services.
Interview on 12/12/24 at 3:39 p.m. the Administrator stated her expectation for wound care was that the
wound care be completed appropriately with proper hand hygiene and aseptic technique. The Administrator
said wound care was a whole process and the expectation was it be done properly.
Review of the facility's policy and procedure on Treatment Table, dated 2003, revealed:
Wash hands, put on gloves,
Place wax paper on wound care bedside table or small cart
Gather treatment supplies (i.e. medicine, tape, extra gloves, etc.) Open up and place on top of wax paper.
One end will be considered clean, and the other end of the table will be open for dirty (To replace scissors
etc. to be cleaned)
Place wax paper over top of supplies.
On open end place linens, saline, red bag, scissors, pen camera, etc. on top of second cover of wax paper.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676068
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676068
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Manor Nursing and Rehabilitation Center
1915 Greenwood St
San Angelo, TX 76901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
After treatment place dirty linens, red bags, scissors, pen etc. to be cleaned on open end (considered dirty
end of table).
Wash hands, take bed side table/cart to treatment cart. Put on gloves. Discard linens, red bags etc. using
universal precautions. Clean scissors, pen, etc. with alcohol prep.
Residents Affected - Few
Clean top of treatment cart, bedside table/cart with disinfectant. Remove gloves. Wash hands.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676068
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676068
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cedar Manor Nursing and Rehabilitation Center
1915 Greenwood St
San Angelo, TX 76901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0910
Ensure resident rooms meet each resident's needs.
Level of Harm - Potential for
minimal harm
Based on observation, interview, and record review, the facility failed to have certified resident rooms
equipped for adequate nursing care, comfort, and privacy for 33 of 85 rooms (Rooms 701-710, 712-714,
717-722, 801-813, and 815).
Residents Affected - Some
The facility failed to have 38 Title 18 beds in B Building resident ready.
The facility failed to have 24 Dually Certified (Title 19/19) beds in B Building resident ready.
This failure could affect residents by placing them at risk of residing in rooms without proper furnishings and
privacy.
The findings included:
Review of the facility-completed Form 3740 Bed Classification, completed and signed by the Administrator
on 12/10/24, documented the facility identified rooms 701-710, 712, 714, 717-719, and 801-805 as Title 18
Medicare-Only beds for both A and B beds in each room for a total of 38 beds. Form 3740 documented the
facility identified rooms 709, 713-A, 720-722, 806, 807, 808-A, 810-A, 811, 812-A, 813, and 815 as dually
certified (Title 18/19) for a total of 24 beds.
Observation of B Building on 12/11/24 at 3:15 pm revealed 33 rooms that were not in use. All 33 rooms
were not resident ready and could not be made resident ready within a reasonable timeframe due to B
Building having not been in use for residents since 2020.
In an interview on 12/11/24 at 3:35 pm with Corporate Compliance RN stated there was no possibility of
getting all 33 rooms livable for residents in 24 hours. He stated it would take deep cleaning and removal of
items being stored in the building to make the rooms adequate for housing residents.
In an interview on 12/11/24 at 4:55 pm with the Administrator, she stated that the building had been used
for storage since before she started working in the facility in 2023. She stated there had been no residents
housed in the building in 4 years. The Administrator stated that the corporate plan was to remodel/update
the building and use it for a rehabilitation unit, but due to low census, the remodel/renovation had not been
priority. She stated that everything in the building was functional, but it needed to be thoroughly cleaned
and have some cosmetic repairs done before it would be suitable for residents. She stated that the
corporation did not want to lose the rooms and would not allow them to be declassified due to the cost
recertifying the beds.
In an interview on 12/12/24 at 5:11 pm, the Administrator stated that there was no facility or corporate
policy regarding bed classification.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676068
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F910 - Resident Rooms
Ensure resident rooms meet each resident's needs.
FAQ · About this visit
Common questions about this visit
What happened during the December 12, 2024 survey of Cedar Manor Nursing and Rehabilitation Center?
This was a inspection survey of Cedar Manor Nursing and Rehabilitation Center on December 12, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Cedar Manor Nursing and Rehabilitation Center on December 12, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.