Cardigan Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Cardigan Nursing & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF761Feb 1, 2024

  Based on observation and interview, the facility failed to ensure that all biologicals and medications no longer in use (medication discontinued or resident no longer at the facility) were properly stored and/or disposed of. Specifically, the facility failed to ensure the medications in the storage room were stored securely and in locked plastic containers. Findings include: On [DATE] at 3:47 P.M., the surveyor inspected the facility's medication storage room with Unit Manager #1. During the inspection, the surveyor observed two large, unsecured/unlocked plastic containers on the counter to the right-hand side of the sink filled with medication cards (blister pack cards) with various resident names on them. […]

• No harm, potential for more than minimal, widespreadF880Feb 1, 2024

  Based on document review and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to have a written water management plan and documentation to ensure a facility risk assessment was conducted to identify where Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens could grow and spread in the facility's water system. […]

• No harm, potential for more than minimal, widespreadF812Mar 31, 2022

  Based on observation and staff interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility 1. Failed to handle ready to eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination; and 2. Failed to maintain the cleanliness of one of one resident kitchenettes. Findings include: 1. On 03/29/22 at 04:45 P.M., the surveyor observed Cook #1 plating the dinner meal which consisted of a grilled ham and cheese sandwich, seafood chowder, potato chips, cheesecake with strawberries with an alternitive choice of a tuna salad sandwich. […]

• No harm, potential for more than minimal, patternF585Mar 18, 2025

  Based on observation, interview, and policy review, the facility failed to: 1. Ensure grievance forms were available in resident care and public areas, so residents and/or visitors were able to access the forms without requesting staff assistance; and 2. Ensure the facility's grievance policy included all the required elements. Findings include: 1. On 3/18/25 at 9:36 A.M., the surveyor toured the unit and was unable to locate grievance forms. The Administrator joined the surveyor and said the forms were kept in a cabinet behind the nurses' station. She said they were not easily accessible to the residents and/or visitors. […]

• No harm, potential for more than minimal, patternF679Mar 18, 2025

  Based on records reviewed and interviews, the facility failed to ensure activity programs were offered consistently on Sundays to meet the needs of residents residing on one of one units in the facility. Findings include: Review of the facility's policy titled Activities, dated 1/5/23, indicated but was not limited to: - Policy: It is the policy of this facility to provide an ongoing program to support residents in the choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychological well-being. […]