Deficiency Records for Terence Cardinal Cooke Health Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Terence Cardinal Cooke 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 | 2023-08-18 | 2023-10-09 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-10-06 | 2022-11-30 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2022-10-06 | 2022-11-30 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-10-06 | 2022-11-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-06 | 2022-11-30 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-10-06 | 2022-11-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-06 | 2022-11-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-06 | 2022-11-18 | 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 | 2022-10-06 | 2022-11-18 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-10-06 | 2022-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-06 | 2022-11-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-06 | 2022-11-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-06 | 2022-11-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-06 | 2022-11-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-06 | 2022-11-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-15 | 2022-09-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-15 | 2021-04-16 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-01-31 | 2020-03-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-31 | 2020-03-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-31 | 2020-03-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-31 | 2020-03-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-01-31 | 2020-03-20 | N |
| 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. | Health | 2020-01-31 | 2020-03-20 | 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 | 2020-01-31 | 2020-03-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-31 | 2020-03-20 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-01-31 | 2020-03-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-31 | 2020-03-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-31 | 2020-03-20 | 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 | 2020-01-31 | 2020-03-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-31 | 2020-03-20 | N |
| Dispose of garbage and refuse properly. | Health | 2020-01-31 | 2020-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-31 | 2020-03-20 | N |
| Develop a communication plan. | Fire Safety | 2018-05-03 | 2018-07-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-03 | 2018-07-25 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-05-03 | 2018-07-25 | N |
| Provide two separate exits in rooms of more than 1000 square feet. | Fire Safety | 2018-05-03 | 2018-07-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-05-03 | 2018-07-25 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-05-03 | 2018-07-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-05-03 | 2018-07-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-03 | 2018-07-25 | N |
