Deficiency Records for The Cedars
Updated as of March 01, 2021
This is not the most recent data for The Cedars. For the most recent information, click here.
A list of the most recent deficiencies for The Cedars. 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 | 2019-08-21 | 2019-09-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-08-21 | 2019-09-20 | N |
| Establish methods for sharing information. | Fire Safety | 2019-08-21 | 2019-09-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-21 | 2019-09-20 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-08-21 | 2019-09-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-21 | 2019-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-21 | 2019-09-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-21 | 2019-09-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-21 | 2019-09-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-21 | 2019-09-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-09 | 2019-09-19 | 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 | 2019-09-09 | 2019-09-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-09 | 2019-09-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-09 | 2019-09-19 | 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 | 2019-09-09 | 2019-09-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-09 | 2019-09-19 | 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 | 2019-09-09 | 2019-09-19 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Be properly staffed | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-22 | 2019-02-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-22 | 2019-01-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-29 | 2018-12-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-11-29 | 2018-12-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-29 | 2018-12-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-29 | 2018-12-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-29 | 2018-12-17 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-11-29 | 2018-12-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-06-27 | 2018-07-05 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-11-09 | 2017-11-17 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-11-09 | 2017-11-17 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-09 | 2017-11-17 | N |
| Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. | Health | 2017-11-09 | 2017-11-17 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-11-09 | 2017-11-17 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-11-09 | 2017-11-17 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-11-09 | 2017-11-17 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-11-09 | 2017-11-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-04-25 | 2017-06-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-04-25 | 2017-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-04-25 | 2017-06-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-04-25 | 2017-06-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-04-25 | 2017-06-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-04-25 | 2017-06-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-04-25 | 2017-06-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-04-25 | 2017-06-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-04-25 | 2017-06-15 | N |
