A list of the most recent deficiencies for Canterbury at Cedar Grove. 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? |
|---|---|---|---|---|
| Dispose of garbage and refuse properly. | Health | 2023-07-26 | 2023-09-25 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-07-26 | 2023-08-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-07-26 | 2023-08-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-07-26 | 2023-08-18 | 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 | 2023-07-26 | 2023-08-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-26 | 2023-08-18 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-07-26 | 2023-08-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-26 | 2023-08-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-07-26 | 2023-08-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-07-26 | 2023-08-18 | 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 | 2023-07-26 | 2023-08-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-26 | 2023-08-18 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-26 | 2023-08-18 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-07-26 | 2023-08-18 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-07-26 | 2023-08-18 | 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 | 2023-07-26 | 2023-08-18 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-07-26 | 2023-08-18 | 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 | 2023-07-26 | 2023-08-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-26 | 2023-08-18 | 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 | 2023-07-26 | 2023-08-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-07-26 | 2023-08-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-07-26 | 2023-08-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-26 | 2023-08-18 | N |
| Keep all essential equipment working safely. | Health | 2023-07-26 | 2023-08-18 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-07-26 | 2023-08-18 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-07-26 | 2023-08-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-26 | 2023-08-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-26 | 2023-08-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-26 | 2023-08-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-14 | 2022-02-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-14 | 2022-01-31 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-06-10 | 2021-07-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-10 | 2021-07-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-10 | 2021-07-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-10 | 2021-07-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-10 | 2021-07-30 | N |
| Dispose of garbage and refuse properly. | Health | 2021-06-10 | 2021-07-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-10 | 2021-07-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-10 | 2021-07-30 | N |
| Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2021-06-10 | 2021-07-01 | 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 | 2019-08-07 | 2019-09-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-07 | 2019-09-24 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-08-07 | 2019-09-24 | 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 | 2019-08-07 | 2019-09-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-07 | 2019-09-24 | N |
| Dispose of garbage and refuse properly. | Health | 2019-08-07 | 2019-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-07 | 2019-09-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-07 | 2019-09-24 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-08-07 | 2019-09-24 | N |
