Deficiency Records for Cedar Grove Respiratory and Nursing Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Cedar Grove Respiratory and Nursing Center. 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? |
|---|---|---|---|---|
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-18 | 2023-06-15 | Y |
| 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 | 2023-05-18 | 2023-06-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-18 | 2023-06-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-18 | 2023-06-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-18 | 2023-06-15 | 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 | 2023-05-18 | 2023-06-15 | 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 | 2023-05-18 | 2023-06-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-18 | 2023-06-15 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-05-18 | 2023-06-15 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-05-18 | 2023-06-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-18 | 2023-06-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-18 | 2023-06-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-18 | 2023-06-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-18 | 2023-06-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-02-23 | 2022-03-25 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-02-23 | 2022-03-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-02-23 | 2022-03-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-23 | 2022-03-25 | 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 | 2022-02-23 | 2022-03-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-23 | 2022-03-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-23 | 2022-03-25 | 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 | 2022-02-23 | 2022-03-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-02-23 | 2022-03-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-23 | 2022-03-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-23 | 2022-03-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-02-23 | 2022-03-25 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-02-23 | 2022-03-25 | 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 | 2022-02-23 | 2022-03-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-23 | 2022-03-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-02-23 | 2022-03-25 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-23 | 2022-03-25 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-02-23 | 2022-03-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-02-23 | 2022-03-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-02-23 | 2022-03-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-23 | 2022-03-25 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-23 | 2022-03-25 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-02-23 | 2022-03-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-23 | 2022-03-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-23 | 2022-03-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-23 | 2022-03-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-21 | 2020-04-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-21 | 2020-04-15 | N |
| Post nurse staffing information every day. | Health | 2020-02-21 | 2020-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-21 | 2020-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-21 | 2020-04-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-02-21 | 2020-04-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-21 | 2020-04-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-21 | 2020-04-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-21 | 2020-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-21 | 2020-04-15 | N |
