A list of the most recent deficiencies for Cathedral Health Care Center. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-09 | 2024-02-02 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Develop a communication plan. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-02 | 2023-11-01 | 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 | 2023-10-02 | 2023-11-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-02 | 2023-11-01 | 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 | 2023-10-02 | 2023-11-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-10-02 | 2023-11-01 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-09-11 | 2023-10-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-11 | 2023-10-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-11 | 2023-10-06 | 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 | 2023-09-11 | 2023-10-06 | 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 | 2023-09-11 | 2023-10-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-11 | 2023-10-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-11 | 2023-10-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-19 | 2022-06-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-21 | 2021-10-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-21 | 2021-10-08 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-07-22 | 2021-08-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-07-22 | 2021-08-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-07-22 | 2021-08-15 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-07-22 | 2021-08-15 | 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 | 2021-07-22 | 2021-08-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-22 | 2021-08-15 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-07-22 | 2021-08-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-15 | 2021-08-13 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-15 | 2021-08-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-08-13 | 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 | 2021-07-15 | 2021-08-13 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-07-15 | 2021-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-15 | 2021-08-13 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-08 | 2020-02-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-11 | 2019-12-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-11 | 2019-12-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-11 | 2019-11-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-11 | 2019-11-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-10-11 | 2019-11-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-11 | 2019-11-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-11 | 2019-11-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-11 | 2019-11-15 | 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 | 2019-10-11 | 2019-11-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-11 | 2019-11-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-11 | 2019-11-15 | 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 | 2019-10-11 | 2019-11-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-11 | 2019-11-15 | N |
