Deficiency Records for Northern Cardinal Rehabilitation and Nursing
Updated as of April 01, 2024
A list of the most recent deficiencies for Northern Cardinal Rehabilitation and Nursing. 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? |
|---|---|---|---|---|
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-05-03 | 2023-11-01 | N |
| Meet other general requirements. | Fire Safety | 2023-05-03 | 2023-06-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-05-03 | 2023-06-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-05-03 | 2023-06-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-03 | 2023-06-01 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-05-03 | 2023-06-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-03 | 2023-06-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-04-14 | 2023-05-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-14 | 2023-05-16 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-04-14 | 2023-05-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-14 | 2023-05-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-14 | 2023-05-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-14 | 2023-05-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-14 | 2023-05-16 | 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 | 2023-04-14 | 2023-05-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-14 | 2023-05-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-14 | 2023-05-16 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-04-14 | 2023-05-16 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-04-14 | 2023-05-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-14 | 2023-05-16 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-14 | 2023-05-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-14 | 2023-05-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-14 | 2023-05-16 | Y |
| Report COVID19 data to residents and families. | Health | 2023-04-14 | 2023-05-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-10 | 2021-10-01 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-08 | 2019-12-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-08 | 2019-12-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-08 | 2019-12-04 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-10-08 | 2019-12-04 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-10-08 | 2019-12-04 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-10-03 | 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 | 2019-10-03 | 2019-11-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-03 | 2019-11-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-03 | 2019-11-15 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-03 | 2019-11-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-03 | 2019-11-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-03 | 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 | 2019-10-03 | 2019-11-15 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-10-03 | 2019-11-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-03-19 | 2018-06-01 | N |
| Provide appropriate foot care. | Health | 2018-03-19 | 2018-06-01 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-03-19 | 2018-05-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-03-19 | 2018-05-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-03-19 | 2018-05-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-03-19 | 2018-05-17 | N |
| Respond appropriately to all alleged violations. | Health | 2018-03-19 | 2018-05-17 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-03-19 | 2018-05-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-19 | 2018-05-17 | 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 | 2018-03-19 | 2018-05-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-19 | 2018-05-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-19 | 2018-05-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-03-19 | 2018-05-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-03-19 | 2018-05-17 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-03-19 | 2018-05-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-19 | 2018-05-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-19 | 2018-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-19 | 2018-05-17 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-03-19 | 2018-05-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-03-19 | 2018-05-17 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-03-19 | 2018-05-17 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-03-19 | 2018-05-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-03-19 | 2018-05-17 | N |
| Meet the requirements of an integrated health system. | Fire Safety | 2018-03-19 | 2018-05-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-03-22 | 2018-05-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-03-22 | 2018-05-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-03-22 | 2018-05-02 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-03-22 | 2018-05-02 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-03-22 | 2018-05-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-22 | 2018-05-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-22 | 2018-05-02 | N |
