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Deficiency Records for Terence Cardinal Cooke Health Care Center

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.

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
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

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