Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record reviews and interviews, the facility failed to ensure the representative of one (Resident #17) of two
residents sampled for hospitalizations received a written notice of transfer and that the Office of the State
Long-Term Care Ombudsman received copies of the facility-initiated transfer or discharge notice for
residents with an unplanned transfer.
Findings included:
Resident #17 was originally admitted to the facility on [DATE] with a recent admit date of 1/3/2021. The
Profile Face Sheet included diagnoses not limited to chronic diastolic heart failure and Chronic Stage 3
Kidney Disease. The Face Sheet indicated the resident had a Power of Attorney (POA).
The quarterly Minimum Data Set (MDS), completed 10/6/2020, indicated Resident #17 had a Brief
Interview of Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. The admission
MDS, completed 1/10/2021, indicated the resident had scored 4 out of 15 on the BIMS, identifying a severe
cognitive impairment.
A review of Resident #17's clinical record identified that the resident was transferred to an acute care facility
on 12/31/20 after the resident presented with rectal bleeding. An Interdisciplinary note, dated 12/31/20 at
9:50 a.m., indicated that 911 was called, physician's office was called, an order was received to transfer to
the hospital via 911 and the resident's son was called and agreed to hospitalization.
The facility provided the AHCA form 3120-0002, Nursing Home Transfer and Discharge Notice, dated
12/31/20. The form did not include the Resident Representative information and identified that the form was
required for those transfers or discharges initiated by the nursing home facility, and not by the resident or by
the resident's physician or legal guardian or representative. The form indicated that the reason for the
transfer was your needs cannot be met in this facility. Page 2 of the Transfer and Discharge Notice was not
signed by the resident or the resident representative. The notice did not include the dates that the notice
was given to the resident, legal guardian, or representative, the local Long-Term Care Ombudsman
Council, or when it was included in the resident's clinical record.
The facility's Notice Before Resident/Legal Representative/Physician-Initiated Transfer or Discharge for
Resident #17's transfer on 12/31/20, indicated that the reason for the transfer was bleeding and that neither
the Nursing Home Transfer and Discharge Notice (AHCA Form 3120-0002) or the Long-Term Care
Ombudsman Council Request for Review of Nursing Home Discharge or Transfer and Long-Term Care
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
105732
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Cedar at Mease Life
910 New York Ave
Dunedin, FL 34698
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Ombudsman Council District Office (AHCA form 3120-0004) were completed and provided to the
resident/legal representative or copied to the medical record.
On 4/2/21 at 4:31 p.m., an interview was conducted with Resident #17's POA. When asked if he had
received or had signed a notification of transfer for the 12/31/20 hospitalization, he stated, No, never.
Residents Affected - Some
Staff Member A, Licensed Practical Nurse (LPN) was asked, on 4/2/21 at 7:43 a.m., what the procedure
was to transfer a resident to the hospital. She stated when sending a resident to the hospital she looked to
see if they had a Do Not Resuscitate (DNR) and would print out the physician orders. She stated the facility
sends a paper bed hold policy and indicated there was another form that also was sent with the resident.
The staff member opened a bottom drawer in the nursing station and pulled out an AHCA
Transfer/Discharge form and placed it back into the drawer, without identifying it as a form that needed to
be completed. She did not locate the other form she had been looking for in the drawer.
At 1:35 p.m. on 4/2/2021, the Social Worker (SW), Nursing Home Administrator (NHA), and the Director of
Nursing (DON) were interviewed regarding the notifications necessary at the time of transfer. The SW
stated at the time of an unplanned transfer the nurse would complete the AHCA Transfer/Discharge form
and if it was a planned transfer she would mail or email it to the representative or give it to the resident if
they were their own person. She stated she dealt with planned discharges. She said, if the nurse was not
able to get a signature it would seem they would make a note (in the chart). The DON stated if the resident
was not their own person, she thought that the social worker would send the form to the representative.
When given the scenario of Resident #17 that had a BIMS score of 4, she stated that the son would be
notified to sign it. The NHA reviewed Resident #17's AHCA form 3120 and stated in an emergency situation
to transfer to the hospital, the nurse would notify the representative and with a resident with a BIMS of 4 the
nurse would note that the notice was received by the representative verbally.
The SW stated, on 4/2/21 at 4:09 p.m., that all the planned discharge forms were sent to the Ombudsman
and that her interpretation from the NHA, during the earlier conversation, was that unplanned discharge
forms were not sent to the Ombudsman.
On 404/02/21 at 4:16 p.m., the NHA stated, At no time are unplanned discharges sent to the Ombudsman.
She stated she was never taught that and then asked this writer if they were supposed to be.
The facility policy, titled Emergency Transfer or Discharge, indicated Emergency transfers or discharges
may be necessary to protect the health and/or well-being of the resident(s). The policy identified that should
it become necessary to make an emergency transfer or discharge to a hospital or other related institution,
our facility will implement the following procedures, which included d. Prepare a transfer form to send with
the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105732
If continuation sheet
Page 2 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Cedar at Mease Life
910 New York Ave
Dunedin, FL 34698
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record reviews and interviews the facility failed to ensure that the representative of one (Resident #17) of
two residents sampled for hospitalizations was notified of the bed-hold policy.
Findings included:
Clinical record review revealed Resident #17 was originally admitted to the facility on [DATE] and
re-admitted on [DATE]. The Profile Face Sheet included diagnoses not limited to chronic diastolic heart
failure and Chronic Stage 3 Kidney Disease. The Face Sheet indicated the resident had a Power of
Attorney (POA) and the payor source was Hospice Medicaid.
The Quarterly Minimum Data Set (MDS), completed 10/6/2020, indicated Resident #17 had a Brief
Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. The admission
MDS, completed 1/10/2021, indicated the resident had scored 4 out of 15 on the BIMS, identifying a severe
cognitive impairment.
Review of the facility's Bed Hold and In-House Transfer Policy, dated 12/31/2020, for Resident #17 indicated
the resident was transferred to an acute care facility on 12/31/2020 and that the notice was given/sent to
Resident #17. Resident #17's bed hold did not indicate if the facility met the 95% of the requirement or if a
paid bed hold was offered. The Bed Hold policy was signed by a Licensed Practical Nurse (LPN) on
12/31/20 and did not indicate the resident representative was notified of the policy and that a copy was sent
with resident at time of discharge. The instructions indicated that a copy must be given to the resident,
family member or legal representative on admission and each time the resident is transferred for
hospitalization or leaves the facility on a therapeutic leave.
At 1:35 p.m. on 4/2/2021, the Nursing Home Administrator (NHA) reviewed the copy of Resident #17's Bed
Hold and In-House Transfer Policy. She stated that for a resident with a BIMS of 4 the Bed Hold would be
discussed with the representative and noted with a verbal acknowledgement. During her review of the
resident's bed hold policy she stated that no it was, not appropriate to give the policy to a resident with a
BIMS score of 4.
A review of the Interdisciplinary notes, dated 12/31/2020, did not indicate that Resident #17's POA was
informed of the Bed Hold Policy.
The policy titled, Bed-Holds and Returns, dated 2001 and revised March 2017, identified that prior to
transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the
bed-hold and return policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105732
If continuation sheet
Page 3 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Cedar at Mease Life
910 New York Ave
Dunedin, FL 34698
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure that dignity was maintained related to
activities of daily living (ADL) care for removal of facial hair for one (Resident #194) out of 12 sampled
residents.
Residents Affected - Few
Findings included:
Multiple observations were made of Resident #194, including on 3/31/21 at 10:30 a.m. and 04/01/21 at
10:45 a.m. During every observation, gray facial hairs approximately 1/4 inch in length were observed
covering the resident's chin. On 04/01/21 at 10:45 a.m. the resident was asked whether she preferred to
have the facial hair on her chin and she said, I don't like hair on my face, and reported that when she had
been living at home home she removed it. The resident reported that nobody in the facility had asked her
about it.
Review of the medical record for Resident #194 revealed she was admitted to the facility on [DATE]. The
Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14
which meant that the resident was cognitively intact, and revealed that she required limited assistance of
one person to perform personal hygiene tasks such as grooming. The care plan revealed that the resident
had a self-care deficit impacting on ADL performance, and staff interventions included providing daily
assistance with grooming needs. There was nothing in the resident's record that revealed a preference for
not having facial hair removed.
Staff E, Certified Nursing Assistant (CNA) was interviewed 04/01/21 at 2:54 p.m. She confirmed she was
the assigned CNA for Resident #194 and said, I just shaved her on Monday, I was off on Tuesday. She
confirmed that shaving facial hair was part of the CNA documentation and asked Staff, F, Unit Manager
(UM) to assist with revealing the documentation in the electronic health record (EHR). Documentation
revealed the following for the ADL task Personal Hygiene Facial Hair (Males and Females) Check and trim
facial hair as necessary:
Monday 03/29/21 7:00 am. - 3:00 p.m. shift was documented by another CNA as Service Not
Provided/Canceled, and there were no entries made by Staff E for that date.
Tuesday 03/30/21 7:00 a.m. - 3:00 p.m. shift was documented by Staff E with a check mark in the field for
Response and nothing else.
Wednesday 03/31/21 7:00 a.m. - 3:00 p.m. shift was documented by Staff E with a check mark in the field
for Response and nothing else.
Thursday 04/01/21 7:00 a.m. - 3:00 p.m. shift was documented by Staff E as a check mark in the field for
Response and nothing else
Review of the staff schedule for Monday 03/20/21, the date Staff E reported she had shaved Resident
194's facial hair, revealed that she was not working at the facility on that date and was working at the facility
on Tuesday, 04/01/21.
Staff F confirmed that the CNA documentation was not complete and did not reveal what had or had
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105732
If continuation sheet
Page 4 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Cedar at Mease Life
910 New York Ave
Dunedin, FL 34698
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0676
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
not been done. She confirmed and revealed that part of the charting included a drop-down menu with
codes including refused that should be entered in status/description field. Staff F said, I will do an
in-service. She confirmed that not providing for removal of facial hair as part of ADL care was a dignity
issue and said, shaving must be offered to women same as men. Staff F stated that facility policy was that if
a resident refused any part of ADL care the CNA was required to re-attempt and after the second refusal
was required to report that to the nurse who would re-approach and document. The Director of Nursing
(DON) entered the conversation and confirmed that CNA documentation for ADL care should include
details about the care performance and if the care was refused the documentation should reflect that.
During these conversations Staff E had left the area. At 3:20 p.m., Staff F was asked to make a
confirmatory observation of Res. #194's facial hair. Upon entry to the resident's room, Staff E was observed
in the bathroom with the resident in the process of shaving her face. Afterwards, Staff E was interviewed
and stated she had offered to shave the resident earlier that day but the resident had refused. Staff E did
not have an explanation for the facial hair observed that morning that did not have the appearance of
having been shaved on Monday as she had stated. She said, well some grow fast.
At 3:50 p.m. on 04/01/21 Resident #194 was interviewed in her room with Staff F present. There was still
some facial hair remaining on her chin and Staff F confirmed it was of a length that should have been
addressed. The resident stated that nobody at the facility had ever offered to shave her face or remove
facial hair since she had been there. At 4:00 p.m. on 04/01/21 Staff G, Registered Nurse (RN) was
interviewed. She confirmed she was the assigned nurse for Resident #194 and confirmed that Staff E had
not reported any refusal of ADL care for the resident that day.
An interview was conducted on 04/01/21 at 4:47 p.m. with the DON. She said, facial hair is a pet peeve of
mine .I tell them (CNAs) that we have to treat the people we work for just like we would treat our loved ones
and I say to them, would you want to see your grandmother like that? .it must be addressed. Regarding
Staff E's performance and reports she said, I'm disappointed in her that she didn't do it (shave the resident)
.now because she didn't document right we can't prove that she did or didn't shave her or offer it but know if
it's not documented it didn't happen. She confirmed that the expectation was that for any refusal of care a
second attempt was to be offered by the CNA and if a resident continued to refuse the CNA was required to
report it to the nurse for follow-up.
Review of the facility policy titled, Quality of Life - Dignity revised August 2009 revealed the following policy
statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity,
respect and individuality. Implementation components included, Treated with dignity means the resident will
be assisted in maintaining and enhancing his or her self-esteem and self-worth .Residents shall be
groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105732
If continuation sheet
Page 5 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Cedar at Mease Life
910 New York Ave
Dunedin, FL 34698
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interviews, and record review, the facility failed to ensure that the medication error
rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and two
errors were identified for two (Residents #41 and #28) of 13 residents observed. These errors constituted a
7.14% medication error rate.
Residents Affected - Few
Findings included:
1. On 4/1/21 at 9:55 a.m., an observation of medication administration with Staff Member D, Registered
Nurse (RN) was conducted with Resident #41. Staff D was observed administering the following
medications:
- Lisinopril 5 milligram (mg) tablet orally
- Amlodipine 5 mg tablet orally
- Vitamin D3 25 microgram (mcg), 1000 units tablet orally
- Sertraline 50 mg - 1.5 tablets orally
A review of the Physician's orders for Resident #41 revealed the following medication order:
- Vitamin D3 - 2000 units by mouth once daily for Vitamin D deficiency
2. On 4/1/21 at 11:52 a.m., an observation of medication administration with Staff Member D, Registered
Nurse (RN) was conducted with Resident #28. Staff D was observed administering the following
medications:
- NovoLog 100 unit/milliliter (mL) 8 units subcutaneously. Blood Glucose - 303.
The administration record indicated that Staff D received a blood glucose level of 303 from Resident #28
prior to the administration of NovoLog. She checked the order and reported that the resident was to receive
8 units of insulin, she removed a NovoLog FlexPen for the medication cart, screwed a needle onto the pen,
removed an alcohol pad from the cart, and dialed the pen to 8 units. The staff member knocked on the
resident door, addressed Resident #28 and asked him if he wanted to go to the dining room. She removed
her gloves that were worn into the room, donned another pair and asked the resident where he wanted the
injection. Resident #28 raised his shirt exposing his abdomen, as Staff D pushed the over-the-bed table
from in front of the resident, moved to stand next to resident, and began to tear open the alcohol pad. The
staff member was asked to step outside with this writer for a moment. When asked if she was supposed to
prime the insulin pen, she stated yes she normally did then asked you mean 2 units? Staff D primed the
pen with 2 units then twisted the dosage selector to 8 units which was administered to the resident.
The Consultant Pharmacist was interviewed, on 4/2/21 at 4:50 p.m., regarding the priming of the insulin
pens and the inaccurate dose of Vitamin D. He stated best practice is probably to prime before each use
but did not believe there was anything in the manufacturer guidelines regarding having to prime the pen
before each use. He stated, the expectation was that the physician orders were followed (regarding the
Vitamin D) and the residents should receive the dosages ordered.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105732
If continuation sheet
Page 6 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Cedar at Mease Life
910 New York Ave
Dunedin, FL 34698
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
At 4:55 p.m. on 4/2/21, the Director of Nursing (DON) stated she was unaware that the FlexPen needed to
be primed, and asked if this writer meant in the beginning? She was informed Yes by this writer. She stated,
I don't think so. The DON stated that the facility had done competencies on use of insulin pens but admitted
it had not been done in a long time.
The manufacturer's informational package insert, located at
https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLog%20FlexPen%
instructed users to give an airshot before each injection. The insert indicated that before injection small
amounts of air may collect in the cartridge during normal use. Users are directed to turn the doses selector
to 2 units, hold Flexpen with needle pointing up, tap the cartridge gently with your finger a few times to
make any air bubbles collect at the top to the cartridge, and to while keeping the needle upwards press the
push button all the way in. A drop of insulin should appear at the needle tip, if not the needle should be
changed and repeat the procedure no more than 6 times. If after six attempts a drop of insulin is not seen
the insert instruct users to not use the Flexpen and to call the manufacturer. The information indicated this
process should be done to prevent injecting air and to ensure proper dosing.
The policy titled Administering Medications, 2001 and revised December 2012, identified Medications shall
be administered in a safe and timely manner, and as prescribed. The policy identified that The Director of
Nursing Services will supervise and direct all nursing personnel who administer medications and/or have
related functions and Medications must be administered in accordance with the orders, including any
required time frame.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105732
If continuation sheet
Page 7 of 7
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
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.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
FAQ · About this visit
Common questions about this visit
What happened during the April 2, 2021 survey of THE CEDAR AT MEASE LIFE?
This was a inspection survey of THE CEDAR AT MEASE LIFE on April 2, 2021. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE CEDAR AT MEASE LIFE on April 2, 2021?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.