Deficiency Records for Cardinal Woods Skilled Nursing and Rehab Ctr
Updated as of October 01, 2019
This is not the most recent data for Cardinal Woods Skilled Nursing and Rehab Ctr. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-14 | 2019-06-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-15 | 2019-06-15 | 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 |
| 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 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-24 | 2019-02-20 | 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 | 2019-01-24 | 2019-02-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-24 | 2019-02-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-09-12 | 2018-10-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-12 | 2018-10-12 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-09-12 | 2018-10-12 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-09-12 | 2018-10-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-04 | 2018-08-07 | Y |
| 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 |
| 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 |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-07-11 | 2017-07-31 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-03-08 | 2017-03-14 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-01-11 | 2017-03-14 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-01-11 | 2017-03-14 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-01-11 | 2017-03-14 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-01-11 | 2017-03-14 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-01-11 | 2017-03-14 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-01-11 | 2017-03-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-01-11 | 2017-03-14 | N |
