Deficiency Records for Cedarburg Health Services
Updated as of January 01, 2022
This is not the most recent data for Cedarburg Health Services. For the most recent information, click here.
A list of the most recent deficiencies for Cedarburg Health Services. 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? |
|---|---|---|---|---|
| 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 | 2021-05-19 | 2021-06-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-19 | 2021-06-17 | 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 | 2021-05-19 | 2021-06-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-19 | 2021-06-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-19 | 2021-06-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-19 | 2021-06-17 | 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 | 2021-05-19 | 2021-06-17 | 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 | 2021-05-19 | 2021-06-17 | 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 | 2021-05-19 | 2021-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-19 | 2021-06-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-18 | 2021-06-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-18 | 2021-06-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-18 | 2021-06-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-01-19 | 2021-02-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-01-19 | 2021-02-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-01-19 | 2021-02-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-01-19 | 2021-02-18 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2020-12-09 | 2021-01-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-12-09 | 2021-01-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-12-09 | 2021-01-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-10 | 2019-10-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-21 | 2019-10-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-21 | 2019-10-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-10 | 2019-10-01 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-10 | 2019-10-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-21 | 2019-10-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-21 | 2019-10-01 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-21 | 2019-10-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-10 | 2019-08-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-10 | 2019-08-21 | 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 | 2019-07-10 | 2019-08-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-10 | 2019-08-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-10 | 2019-08-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-07-10 | 2019-08-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-10 | 2019-08-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-10 | 2019-08-21 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-07-10 | 2019-08-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-10 | 2019-08-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-07-10 | 2019-08-21 | Y |
| 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 | 2019-07-10 | 2019-08-21 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2019-07-10 | 2019-08-21 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-10 | 2019-08-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-10 | 2019-08-21 | Y |
| 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 | 2019-07-10 | 2019-08-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-10 | 2019-08-21 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-07-10 | 2019-08-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-07-10 | 2019-08-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-10 | 2019-08-21 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-07-10 | 2019-08-21 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-26 | 2019-08-05 | 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 | 2018-05-15 | 2018-06-15 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2018-05-15 | 2018-06-15 | 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 | 2018-05-15 | 2018-06-15 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-05-15 | 2018-06-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-15 | 2018-06-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-15 | 2018-06-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-15 | 2018-06-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-15 | 2018-06-15 | 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 | 2018-05-15 | 2018-06-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-05-15 | 2018-06-15 | 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 | 2018-05-15 | 2018-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-15 | 2018-06-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-10 | 2018-06-15 | N |
