A list of the most recent deficiencies for The Villas at 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? |
|---|---|---|---|---|
| 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 | 2023-11-16 | 2023-12-12 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-07-14 | 2023-09-12 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-07-14 | 2023-09-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-14 | 2023-09-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-14 | 2023-09-12 | N |
| Respond appropriately to all alleged violations. | Health | 2023-07-14 | 2023-09-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-07-14 | 2023-09-12 | 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 | 2023-07-14 | 2023-09-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-14 | 2023-09-12 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-14 | 2023-09-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-14 | 2023-09-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-14 | 2023-09-12 | 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 | 2023-07-14 | 2023-09-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-14 | 2023-09-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-12 | 2023-09-12 | 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 | 2023-07-12 | 2023-09-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-12 | 2023-09-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-12 | 2023-09-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-16 | 2023-05-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-15 | 2022-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-26 | 2022-05-24 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-02-01 | 2022-03-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-01 | 2022-03-22 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-09-17 | 2021-10-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-17 | 2021-10-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-17 | 2021-10-26 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-09-17 | 2021-10-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-17 | 2021-10-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-17 | 2021-10-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-09-17 | 2021-10-26 | N |
| Post nurse staffing information every day. | Health | 2021-09-17 | 2021-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-17 | 2021-10-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-17 | 2021-10-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-15 | 2021-10-26 | 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 | 2021-09-10 | 2021-10-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-10 | 2021-10-14 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-06-20 | 2019-07-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-20 | 2019-07-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-20 | 2019-07-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-20 | 2019-07-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-20 | 2019-07-12 | 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 | 2019-06-20 | 2019-07-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-20 | 2019-07-12 | N |
