A list of the most recent deficiencies for Cardinal Care Strategies. 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? |
|---|---|---|---|---|
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-02-08 | 2024-02-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-08 | 2024-02-23 | 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 | 2024-02-08 | 2024-02-23 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-02-08 | 2024-02-23 | 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 | 2024-02-08 | 2024-02-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-08 | 2024-02-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-08 | 2024-02-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-08 | 2024-02-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-08 | 2024-02-23 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-30 | 2024-02-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-01-30 | 2024-02-14 | N |
| 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 | 2024-01-30 | 2024-02-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-01-30 | 2024-02-14 | N |
| 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. | Health | 2024-01-30 | 2024-02-14 | N |
| 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. | Health | 2024-01-30 | 2024-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-30 | 2024-02-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-23 | 2023-11-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-06 | 2023-09-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-06 | 2023-09-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-06 | 2023-09-29 | Y |
| 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. | Health | 2023-06-21 | 2023-07-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-21 | 2023-07-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-14 | 2023-05-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-17 | 2023-05-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-17 | 2023-05-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-17 | 2023-05-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-01 | 2023-05-05 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-03-13 | 2023-05-05 | N |
| Respond appropriately to all alleged violations. | Health | 2023-03-13 | 2023-05-05 | 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 | 2023-03-13 | 2023-05-05 | 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 | 2023-03-13 | 2023-05-05 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-03-13 | 2023-05-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-13 | 2023-05-05 | N |
| 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. | Health | 2023-03-13 | 2023-05-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-20 | 2023-04-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-20 | 2023-04-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-20 | 2023-04-18 | 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 | 2023-03-20 | 2023-04-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-20 | 2023-04-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-20 | 2023-04-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-03-20 | 2023-04-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-20 | 2023-04-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-03-20 | 2023-04-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-20 | 2023-04-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-20 | 2023-04-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-20 | 2023-04-18 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-03-20 | 2023-04-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-04 | 2022-08-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-20 | 2022-05-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-28 | 2022-04-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-23 | 2022-04-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-23 | 2022-04-15 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-02-18 | 2022-04-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-18 | 2022-04-05 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-02-18 | 2022-04-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-18 | 2022-04-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-18 | 2022-04-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-18 | 2022-04-05 | 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 | 2022-02-18 | 2022-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-18 | 2022-04-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Develop a communication plan. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Meet other general requirements. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-03-01 | 2022-03-31 | 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 | 2022-03-01 | 2022-03-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-03-01 | 2022-03-31 | N |
| 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. | Health | 2021-09-09 | 2021-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-09 | 2021-09-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-11 | 2021-06-28 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-03-22 | 2021-03-23 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-03-22 | 2021-03-23 | Y |
