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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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-09-19 | 2024-10-24 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-09-19 | 2024-10-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-09-19 | 2024-10-24 | 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 | 2024-09-19 | 2024-10-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-19 | 2024-10-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-19 | 2024-10-24 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-09-19 | 2024-10-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-19 | 2024-10-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-09-19 | 2024-10-24 | 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 | 2024-09-19 | 2024-10-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-09-19 | 2024-10-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-09-19 | 2024-10-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-09-19 | 2024-10-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-09-19 | 2024-10-24 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-09-19 | 2024-10-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-09-19 | 2024-10-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-19 | 2024-10-24 | N |
| 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 |
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