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Inspection visit

Inspection

CEDARWOOD GARDENSCMS #22546127 citations on this visit
27 citations recorded

Citations

27 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.

  • 0582GeneralS&S Dpotential for harm

    F582 - The facility must—

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0584GeneralS&S Epotential for harm

    F584 - Safe Environment

    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.

  • 0641GeneralS&S Bno actual harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0655GeneralS&S Dpotential for harm

    F655 - Comprehensive Person-Centered Care Planning

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0677GeneralS&S Dpotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0689GeneralS&S Epotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0690GeneralS&S Dpotential for harm

    F690 - Incontinence

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  • 0695GeneralS&S Epotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0699GeneralS&S Dpotential for harm

    F699 - Trauma-informed care

    Provide care or services that was trauma informed and/or culturally competent.

  • 0756GeneralS&S Epotential for harm

    F756 - Drug Regimen Review

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    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.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0842GeneralS&S Bno actual harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0851GeneralS&S Fpotential for harm

    F851 - Mandatory submission of staffing information based on payroll data in a

    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0883GeneralS&S Epotential for harm

    F883 - Influenza and pneumococcal immunizations

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0004GeneralS&S Cno actual harm

    Develop and maintain an Emergency Preparedness Program (EP).

  • 0039GeneralS&S Dpotential for harm

    Conduct testing and exercise requirements.

  • 0041GeneralS&S Epotential for harm

    Implement emergency and standby power systems.

  • 0161GeneralS&S Dpotential for harm

    Use approved construction type or materials.

  • 0321GeneralS&S Dpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0324GeneralS&S Dpotential for harm

    Provide properly protected cooking facilities.

  • 0345GeneralS&S Dpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0712GeneralS&S Fpotential for harm

    F712 - Frequency of physician visits

    Have simulated fire drills held at unexpected times.

  • 0918GeneralS&S Epotential for harm

    F918 - Bathroom Facilities

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0291GeneralS&S Dpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

FAQ · About this visit

Common questions about this visit

What happened during the May 8, 2024 survey of CEDARWOOD GARDENS?

This was a inspection survey of CEDARWOOD GARDENS on May 8, 2024. The surveyor cited 27 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CEDARWOOD GARDENS on May 8, 2024?

Yes, 27 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered."

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.

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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.