THE CEDARS (MCPHERSON, KS) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

Here:	12.4%
Kansas:	14.7%

Percent of long-stay residents who self-report moderate to severe pain

Here:	4.5%
Kansas:	12.8%

Percent of long-stay high-risk residents with pressure ulcers

This Nursing Home:	6.5%
Kansas:	5.4%

Percent of long-stay residents who lose too much weight

Here:	8.2%
Kansas:	7.3%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

This Nursing Home:	37.1%
State:	36.5%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

Here:	7.5%
State:	3.6%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	15.5%
Kansas:	8.2%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	13.6%
State:	9.8%

Percent of long-stay residents who were physically restrained

This Nursing Home:	1.0%
Kansas:	0.5%

Percent of long-stay residents experiencing one or more falls with major injury

This Nursing Home:	8.2%
State:	5.1%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	96.9%
Kansas:	97.2%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	85.7%
Kansas:	95.7%

Percent of short-stay residents who self-report moderate to severe pain

This Nursing Home:	8.6%
State:	23.4%

Percent of short-stay residents with Pressure ulcers that are new or worsened

This Nursing Home:	3.0%
Kansas:	1.9%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	97.0%
Kansas:	87.0%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	92.9%
State:	83.3%

Percent of short-stay residents who newly received an antipsychotic medication

Here:	6.7%
State:	2.8%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	17.9%
Kansas:	23.1%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.530
State:	0.703

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	0.940
State:	0.645

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.470
State:	1.346

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.050
Kansas:	0.050

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.050
Kansas:	0.059

Complaint Deficiency

Signs that state that exit doors are to be kept closed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper backup exit lighting
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Hire sufficient dietary support personnel
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide special eating equipment and utensils for each resident who needs them
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Emergency lighting that can last at least 1 1/2 hours
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
- Harm: Minimal harm or potential for actual harm
- Scope: Few
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Allow residents to easily view the results of the nursing home's most recent survey
- Harm: Potential for minimal harm
- Scope: Many
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few

THE CEDARS - MCPHERSON, KS

Quality Measures

Staff Information

Complaint Deficiency

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