Cardinal Care Strategies

In the surveyor’s words

From the most serious findings on record at Cardinal Care Strategies, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 12, 2025

  Based on interview and record review, the facility failed to prevent resident to resident sexual abuse of two cognitively impaired residents (Residents F and B) by Resident C, who was cognitively intact with intellectual disabilities, for 2 of 5 residents reviewed for abuse. Resident F was found sitting on Resident C's bed while Resident C had his pants down while seated on the bed, exposing his erect penis and Resident F was observed with saliva on his face and mouth. Later the same day, Resident B was found in his bed with feces and blood on his shirt and incontinence brief, with his brief disheveled, and Resident C was in the same room performing self-gratification of his rectum, with feces and blood on his hands. […]

• Immediate jeopardy, isolatedF609Dec 12, 2025

  Based on interview and record review, the facility failed to report an allegation of resident-to-resident sexual abuse immediately to the Administrator to facilitate protection from further abuse when a cognitively impaired resident (Resident F) was found on the bed of another resident (Resident C) who was exposing his erect penis and Resident F was observed with saliva over his face and mouth for 2 of 5 residents reviewed for abuse (Residents F and B). The facility failed to report the allegation to the State Agency once the Administrator was made aware of the allegations. […]

• Immediate jeopardy, isolatedF610Dec 12, 2025

  Based on interview and record review, the facility failed to initiate investigative protocols and protective interventions for allegations of resident-to-resident sexual abuse for 2 of 5 residents reviewed for abuse (Residents F and B) by Resident C when Resident F was found on the bed of Resident C, who was exposing his erect penis while Resident F was observed with saliva over his face and mouth and when Resident B was found with feces and blood on his shirt and brief while Resident C was in the same room performing self-gratification of his rectum later the same day. […]

• Immediate jeopardy, isolatedF689Apr 14, 2023

  A. Based on observation, interview and record review, the facility failed to ensure a resident with known suicidal ideations with plastic bags had interventions in place, including no access to plastic bags for 1 of 3 resident reviewed for accidents (Resident C). The Immediate Jeopardy began on 4/11/23 when a resident with previous suicidal ideations with plastic bags was found by staff applying a plastic bag to her head. During an observation of the resident's room, on 4/13/23, there were plastic bags observed in two trash cans. The DON, ADON, SSD and Medical Records Nurse were notified of the Immediate Jeopardy on 4/13/23 at 3:23 p.m. […]

• Immediate jeopardy, isolatedF689Apr 28, 2022

  Based on record review and interview, the facility failed to ensure a resident with dysphagia and at risk for choking received supervision while eating for 1 of 3 residents at risk for choking. This deficient practice resulted in the resident choking, coded, emergency services being called and the resident died on [DATE]. (Resident B) The immediate jeopardy began on [DATE] when a Certified Nursing Assistant served Resident B a peanut butter and jelly sandwich and left the resident with no assistance or supervision. […]