A list of the most recent deficiencies for Cedarcrest Care 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? |
|---|---|---|---|---|
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-01-09 | 2023-03-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-09 | 2023-03-30 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-16 | 2023-03-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-09 | 2023-03-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-09 | 2023-03-10 | 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 | 2023-02-08 | 2023-03-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Have an externally vented heating system. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-08 | 2023-03-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-08 | 2023-02-17 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-13 | 2023-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-13 | 2023-01-13 | Y |
| 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 | 2022-12-13 | 2022-12-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-13 | 2022-11-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-03 | 2021-09-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-03 | 2021-09-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-25 | 2019-11-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-25 | 2019-11-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-25 | 2019-11-06 | 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 | 2019-09-25 | 2019-11-06 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-09-25 | 2019-11-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-25 | 2019-11-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-25 | 2019-11-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-24 | 2019-11-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-24 | 2019-11-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-01 | 2018-09-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-08-01 | 2018-09-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-01 | 2018-09-05 | N |
| Respond appropriately to all alleged violations. | Health | 2018-08-01 | 2018-09-05 | 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 | 2018-08-01 | 2018-09-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-01 | 2018-09-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-08-01 | 2018-09-05 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-08-01 | 2018-09-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-01 | 2018-09-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-08-01 | 2018-09-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-01 | 2018-09-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-01 | 2018-09-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-01 | 2018-09-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-07-24 | 2018-09-05 | N |
