A list of the most recent deficiencies for Cedarwood Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-27 | 2023-12-07 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-03 | 2023-08-07 | N |
| Use approved construction type or materials. | Fire Safety | 2023-07-03 | 2023-08-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-03 | 2023-08-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-03 | 2023-08-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-03 | 2023-08-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-07-03 | 2023-08-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-03 | 2023-08-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-03 | 2023-08-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-03 | 2023-08-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-03 | 2023-08-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-03 | 2023-08-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-03 | 2023-08-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-29 | 2023-07-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-29 | 2023-07-25 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-29 | 2023-07-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-29 | 2023-07-25 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-06-29 | 2023-07-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-29 | 2023-07-25 | N |
| Provide appropriate foot care. | Health | 2023-06-29 | 2023-07-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-06-29 | 2023-07-25 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-06-29 | 2023-07-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-07-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-29 | 2023-07-25 | N |
| Keep all essential equipment working safely. | Health | 2023-06-29 | 2023-07-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-14 | 2023-06-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-02 | 2023-05-08 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-03-29 | 2023-04-11 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-02 | 2023-03-02 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-30 | 2023-02-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-30 | 2023-02-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-24 | 2023-01-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-29 | 2022-12-19 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-09-09 | 2022-10-25 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-12 | 2022-08-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-28 | 2022-05-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-28 | 2022-05-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-28 | 2022-05-18 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-02-16 | 2022-03-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-17 | 2021-12-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-17 | 2021-12-08 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-10-01 | 2021-10-28 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-10-01 | 2021-10-28 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-09-23 | 2021-10-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-23 | 2021-10-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-13 | 2021-06-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-13 | 2021-06-03 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-11 | 2019-07-01 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-04-18 | 2019-05-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-18 | 2019-05-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-04-18 | 2019-05-28 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-04-18 | 2019-05-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-18 | 2019-05-28 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-04-18 | 2019-05-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-04-18 | 2019-05-28 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-04-18 | 2019-05-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-05-24 | 2018-07-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-24 | 2018-07-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-05-24 | 2018-07-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-05-24 | 2018-07-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-24 | 2018-07-12 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-05-24 | 2018-07-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-24 | 2018-07-12 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-06-05 | 2018-06-27 | N |
| Use approved construction type or materials. | Fire Safety | 2018-06-05 | 2018-06-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-06-05 | 2018-06-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-06-05 | 2018-06-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-05 | 2018-06-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-06-05 | 2018-06-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-06-05 | 2018-06-27 | N |
