Deficiency Records for Cardinal Woods Skilled Nursing and Rehab Ctr
Updated as of April 01, 2024
A list of the most recent deficiencies for Cardinal Woods Skilled Nursing and Rehab Ctr. 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? |
|---|---|---|---|---|
| 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 | 2024-02-07 | 2024-02-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-05 | 2023-12-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-14 | 2023-03-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-14 | 2023-03-07 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-14 | 2023-03-07 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-27 | 2022-07-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-27 | 2022-07-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-27 | 2022-07-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-27 | 2022-07-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-27 | 2022-07-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-27 | 2022-07-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-06-27 | 2022-07-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-27 | 2022-07-22 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-06-27 | 2022-07-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-27 | 2022-07-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-27 | 2022-07-22 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-27 | 2022-07-22 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-27 | 2022-07-22 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-06-27 | 2022-07-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-27 | 2022-07-22 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-06-27 | 2022-07-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-27 | 2022-07-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-27 | 2022-07-22 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-07 | 2022-07-22 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-02-16 | 2022-02-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-16 | 2022-02-25 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-02-16 | 2022-02-25 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-02-16 | 2022-02-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-13 | 2022-01-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-13 | 2022-01-14 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-12-13 | 2022-01-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-23 | 2021-09-24 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-08-30 | 2021-09-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-30 | 2021-09-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-08 | 2021-07-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-08 | 2021-07-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-08 | 2021-07-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-21 | 2021-05-26 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-05-21 | 2021-05-26 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-21 | 2021-05-26 | Y |
| 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 | 2019-05-16 | 2019-06-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-05-16 | 2019-06-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-05-16 | 2019-06-15 | N |
| Respond appropriately to all alleged violations. | Health | 2019-05-16 | 2019-06-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-16 | 2019-06-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-16 | 2019-06-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-16 | 2019-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-16 | 2019-06-15 | N |
| Have policies on smoking. | Health | 2019-05-16 | 2019-06-15 | N |
| Develop a communication plan. | Fire Safety | 2019-05-14 | 2019-06-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-14 | 2019-06-15 | 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 | 2019-05-14 | 2019-06-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-05-14 | 2019-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-14 | 2019-06-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-05-14 | 2019-06-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-14 | 2019-06-15 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-05-14 | 2019-06-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-05-14 | 2019-05-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-14 | 2019-05-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-05 | 2018-04-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-05 | 2018-04-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-04-05 | 2018-04-25 | 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 | 2018-04-05 | 2018-04-25 | 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 | 2018-04-05 | 2018-04-25 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2018-04-05 | 2018-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-05 | 2018-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-05 | 2018-04-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-05 | 2018-04-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-04-05 | 2018-04-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-05 | 2018-04-25 | N |
