A list of the most recent deficiencies for Complete Care 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? |
|---|---|---|---|---|
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-08-18 | 2023-09-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-18 | 2023-09-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-18 | 2023-09-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-18 | 2023-09-29 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-18 | 2023-09-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-18 | 2023-09-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-18 | 2023-09-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-18 | 2023-09-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-18 | 2023-09-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-18 | 2023-09-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-18 | 2023-09-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-18 | 2023-09-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-18 | 2023-09-07 | N |
| 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 | 2023-08-18 | 2023-09-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-18 | 2023-09-07 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-08-18 | 2023-09-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-09-03 | 2021-09-27 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-09-03 | 2021-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-03 | 2021-09-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-09-03 | 2021-09-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-10-09 | 2019-11-12 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-10-09 | 2019-11-12 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-10-09 | 2019-11-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-09 | 2019-11-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-09 | 2019-11-12 | 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 | 2019-10-09 | 2019-11-12 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-09 | 2019-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-09 | 2019-11-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-09 | 2019-11-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-09 | 2019-11-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-09 | 2019-11-12 | N |
