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Deficiency Records for The Villas at The Cedars

A list of the most recent deficiencies for The Villas at The Cedars. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for The Villas at The Cedars. 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?
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-08-13 2024-08-28 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 2023-11-16 2023-12-12 Y
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2023-07-14 2023-09-12 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2023-07-14 2023-09-12 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-07-14 2023-09-12 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-07-14 2023-09-12 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 2023-07-14 2023-09-12 N
Provide activities to meet all resident's needs. Health 2023-07-14 2023-09-12 N
Provide enough food/fluids to maintain a resident's health. Health 2023-07-14 2023-09-12 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 2023-07-14 2023-09-12 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2023-07-14 2023-09-12 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-07-14 2023-09-12 Y
Respond appropriately to all alleged violations. Health 2023-07-14 2023-09-12 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-07-14 2023-09-12 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-07-14 2023-09-12 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-07-12 2023-09-12 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 2023-07-12 2023-09-12 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2023-07-12 2023-09-12 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-07-12 2023-09-12 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-05-16 2023-05-16 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-12-15 2022-12-30 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-04-26 2022-05-24 Y
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 2022-02-01 2022-03-22 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2022-02-01 2022-03-22 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2021-09-17 2021-10-26 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-09-17 2021-10-26 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-09-17 2021-10-26 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2021-09-17 2021-10-26 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-09-17 2021-10-26 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-09-17 2021-10-26 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 2021-09-17 2021-10-26 N
Post nurse staffing information every day. Health 2021-09-17 2021-10-26 N
Provide and implement an infection prevention and control program. Health 2021-09-17 2021-10-26 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2021-09-17 2021-10-26 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-09-15 2021-10-26 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2019-06-20 2019-07-12 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2019-06-20 2019-07-12 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2019-06-20 2019-07-12 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-06-20 2019-07-12 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2019-06-20 2019-07-12 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 2019-06-20 2019-07-12 N
Provide and implement an infection prevention and control program. Health 2019-06-20 2019-07-12 N

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