A list of the most recent deficiencies for Cedars The. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-19 | 2023-11-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-10-19 | 2023-11-20 | N |
| Develop a communication plan. | Fire Safety | 2023-10-19 | 2023-11-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-10-19 | 2023-11-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-19 | 2023-11-20 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-10-19 | 2023-11-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-19 | 2023-11-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-19 | 2023-11-20 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-10-19 | 2023-11-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-10-19 | 2023-11-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-19 | 2023-11-20 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-10-19 | 2023-11-04 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-08 | 2023-09-28 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-09-08 | 2023-09-28 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-09-08 | 2023-09-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-08 | 2023-09-28 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-08 | 2023-09-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-08 | 2023-09-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-08 | 2023-09-28 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-08-09 | 2023-08-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-08 | 2023-06-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-13 | 2023-04-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-13 | 2023-04-11 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-12-07 | 2023-02-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-07 | 2023-02-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-22 | 2022-12-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-09 | 2022-12-16 | 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 | 2022-11-09 | 2022-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-21 | 2022-10-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-02 | 2022-08-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-02 | 2022-08-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-20 | 2022-08-10 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-08-27 | 2021-09-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-27 | 2021-09-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-27 | 2021-09-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-27 | 2021-09-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-07 | 2021-09-20 | N |
| Have an externally vented heating system. | Fire Safety | 2021-09-07 | 2021-09-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-07 | 2021-09-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-09 | 2021-07-09 | Y |
