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Deficiency Records for Cathedral Health Care Center
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.
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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-09-13 | 2024-10-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-09-13 | 2024-10-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-13 | 2024-10-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-13 | 2024-10-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-09-13 | 2024-10-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-09-13 | 2024-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-13 | 2024-10-12 | N |
| Meet other general requirements. | Fire Safety | 2024-09-24 | 2024-10-11 | 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 | 2024-09-24 | 2024-10-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-09-24 | 2024-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-24 | 2024-10-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-09-24 | 2024-10-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-24 | 2024-10-11 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-08-23 | 2024-09-07 | Y |
| 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 |
| 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 |
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