Cardinal Nursing And Rehabilitation Center

Based on observation and interview the facility failed to store and prepare food in a sanitary manner in 1 of 1 kitchens and 1 of 2 nourishment pantries. This deficient practice had the potential to affect 58 residents who food from the kitchen and/or pantry. Finding includes: During a tour of the kitchen with [NAME] 2 on 6/9/24 at 9:02 A.M., the following was observed: -Uncovered coffee filters were stored on the lower shelf of a table right next to a trash can for the hand washing sink. -Dead bugs and dirt were noted in the light fixtures in the dry storage area and in the food prep areas of the kitchen. -Metal wire racks in the dry storage area were dusty and had rust and grime on them. -A fan and filter in the walk-in refrigerator were black with dust and dirt. -The knife storage rack was grimy and dusty. -Walls in the food preparation area were dirty with a build up of brown and black grime. During an interview on 6/11/24 at 9:17 A.M., the Dietary Supervisor indicated maintenance was working on replacing the light fixtures covers. She agreed the walls and the knife storage unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain the cleanliness of resident's personal refrigerators, for 2 of 3 personal refrigerators that were observed. (Resident 42 & 24) Findings include: 1. An observation of Resident 42's refrigerator was completed on 6/10/2024 at 9:13 A.M and on 6/11/2024 at 11: 16 A.M. with the Director of Nursing (DON). The following was observed: - 7 undated peanut butter and jelly sandwiches without expiration dates - A dark brown, sticky solution covering the bottom of the refrigerator - A heavy amount of ice build-up on freezer compartment During an interview on 6/10/2024 at 9:14 A.M., Resident 42 indicated he used his refrigerator for snacks and drinks. 2. An observation of Resident 24's refrigerator was completed on 6/10/2024 at 10:30 A.M and on 6/11/2024 at 11: 16 A.M. with the DON. The following was observed: - A foul odor was detected when the refrigerator door was opened - A small, clear container labeled ground turkey and with an expiration date of 6/4/2024 - 2 opened diet cokes without opened dates - A thick…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for resident rights and dignity, were treated in a manner that respected the resident's dignity, when the resident was photographed without permission by a facility employee (Resident B). Findings include: On 12/12/23 at 12:30 P.M., Resident B was observed in her room sitting in a wheelchair near the bed. The resident was well groomed and in appropriate casual wear. During an interview at that time, Resident B, stood from the wheelchair and transferred herself to her bed without difficulty. The resident indicated that she and Employee 2 had become close friends and that she felt like a granddaughter to her. She indicated sometime in June or July of 2023; she sent a text to Employee 2 requesting that she bring a bag of popcorn to her room from a facility activity. Resident B indicated she fell asleep in her room before Employee 2 delivered the popcorn and that she later sent her a text that showed Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to notify the attending physician for a change in condition for 1 of 1 resident reviewed for change in condition. (Resident B) Findings include: During a record review, conducted 11/7/2023 at 10:12 A.M., the 5- day admission Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had an intact cognition. She was independent for mobility and self-care. Active diagnoses included but were not limited to: chronic obstructive pulmonary disease, anxiety, atrial fibrillation, and cardiac pacemaker. She used oxygen as needed. She took a daily anticoagulant. Physician orders included, but were not limited to: -10/24/2023 Oxygen at l liter per nasal cannula as needed -10/23/2023 Cardizem 180 milligrams (mg) oral once a day -10/20/2023 Eliquis 2.5 mg oral twice a day A care plan problem, dated 10/24/2023, included, but was not limited to: resident is at risk for alteration in cardiac function related to pacemaker. The goal was for the resident to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure food items in the freezer were dated/labeled and sealed securely after opening and failed to ensure used by dates on foods. This deficient practice had the potential to affect 62 of 64 residents who received meals out of the kitchen. Findings include: On 6/12/23 at 9:28 A.M., during on observation and kitchen tour with the dietary manager, the following was oberserved: - In the pantry of the main kitchen, graham cracker crumbs were in an open bag with no date on the bag indicating when opened. - In the cooler, an open half gallon of milk and a carton of Half and Half had no open date. - In the freezer, two open tubs of ice cream had no open dates. Italian sausage, pork loin chops, beef cubed patties were found to be undated and unsealed. On 6/15/23 at 12:30 P.M., the Regional Nurse Consultant provided a policy titled, Food Storage, revised 5/23 and indicated the policy was the one currently used by the facility. The policy indicated .frozen foods, should be covered or wrapped tightly, labeled and dated with the date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the signed advance directive was updated in the plan of care and physician order for 1 of 25 residents reviewed for advanced directives. (Resident 20) Finding includes: A record review was completed on 6/14/2023 at 2:40 P.M. Diagnoses included, but were not limited to: cerebral infarction and hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. A Physician Orders For Scope of Treatment (POST), dated 5/12/2023, indicated do not attempt resuscitation. A Physician Order, dated 4/5/2022, indicated full code. A Care Plan, dated 2/19/2020, indicated resident/legal representative prefers a full code status. During an interview on 6/14/2023 at 10:30 A.M., the Director of Nursing indicated they obtain a code status upon admission, readmission, and revisit during a quarterly care conference. The resient was a do not resuscitate and the order and care plan should have been updated when it was changed. On 6/14/2023 at 10:47 A.M., the Director of Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a notification of change in Medicare covered services was provided for 1 of 3 residents reviewed for Medicare services. (Resident 64) Finding includes: The clinical record for Resident 64 was reviewed on 6/14/2023 at 11:00 A.M. Resident 64 was admitted to the facility on [DATE] and was receiving Medicare Part A Services. Review of the record indicated the resident's last covered Medicare Part A services day was 2/16/2023. The clinical record for Resident 64, reviewed on 6/13/2023 at 1:17 P.M., indicated the resident was admitted to the facility on [DATE] with diagnoses included, but not limited to: hemiparesis and hemiplegia related to subarachnoid hemorrhage, diabetes mellitus, depression, and dysphagia. The resident was receiving Medicare Part A skilled services when she was admitted , and her last covered Medicare day was 2/16/2023. The facility Business office provided documentation that a skilled care ABN (Advanced Beneficiary Notice of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to protect a residents right to be free from verbal abuse for 1 of 1 resident reviewed for abuse. (Resident C) Finding includes: Review of a facility reported incident, on 6/11/2023 indicated Resident C reported a staff person to be verbally abusive to her. The report indicated the identified employee was suspended pending an investigation, alert and oriented residents were interviewed to determine any concerns with staff they might have, the identified employee received Customer service education and the progressive discipline policy was followed. Resident C was to be monitored for any psychosocial concerns regarding the event. There was no specific information regarding the event on the facility reported incident. However, review of the incident investigation, provided upon request on 6/14/2023 indicated the following: On 6/8/2023, two activity aides (Employee 15 and 16) had transported Resident C on the facility bus to an outside physician's office for an appointment. During the bus ride to the appointment, Employee 16 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure showers were provided for 1 out of 3 Residents reviewed for activities of daily living. (Resident 50) Finding includes: During an interview on 6/13/2023 at 9:11 A.M., Resident 50 indicated he preferred to take a shower but does not get one. During an interview on 6/14/2023 at 1:28 P.M., Resident 50 indicated he did not have a shower this week. During an interview on 6/16/2023 at 1:41 P.M., the resident indicated he had not received a shower this week. A record review was completed on 6/15/2023 at 2:00 P.M. Diagnoses included, but were not limited to: neoplasm of the brain, Diabetes Mellitus, anxiety and depression. A Quarterly Minimum Data Set (MDS) Assessment, dated 5/22/2023, indicated physical help in part of bathing activity. A Preference for Customary Routine and Activities, dated 4/11/2023, indicated he would like twice a week shower in the P.M. and that it was very important to him to choose between tub bath, shower, and bed/sponge bath. A Care Plan, dated 4/9/2023, indicated resident required assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interviews, the facility failed to ensure Activities of daily living assistance was provided for 2 of 4 residents reviewed. (Resident 20 and 53) Findings include: 1. Resident 53 was observed on 6/12/2023, 6/13/2023 and 6/14/2023 dressed in the common areas and/or at an activity. Her hair was observed to be unkept in appearance and greasy. The clinical record for Resident 53, reviewed on 6/19/23 at 9:16 A.M., indicated the resident had diagnoses included but not limited to: hypertension, chronic kidney disease hyperlipidemia, obesity, insomnia, adjustment disorder with depressed mood, dementia, and major depressive disorder, recurrent, The most recent MDS (Minimum Data Set) assessment for Resident 53, completed on 5/11/2023 for a quarterly review, indicated the resident was severely cognitively impaired and required extensive assist of one for toileting, bathing, dressing, and limited assist of one for personal hygiene. The annual MDS assessment, completed on 4/12/2023, indicated it was very important for the resident to choose between a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure antibiotic medications were administered as directed by the physician's orders and anti- coagulant medication was resumed timely for 1 of 3 residents reviewed. (Resident C) Findings include: The record for Resident C, reviewed on 6/14/2023 at 11:01 A.M., indicated Resident C was admitted with diagnoses included, but not limited to: acute embolism and thrombosis of right lower extremity, thrombocytopenia, repeated falls, muscle weakness, unsteadiness on feet and osteomyelitis of vertebra -cervical and thoracic region. The resident was hospitalized [DATE] - 4/11/2023 for a septic arthritic left hip joint and on 6/8/2023 for an acute deep vein thrombosis. Review of the hospital discharge records for Resident C, completed on 4/11/2023 indicated the resident was to receive enoxaparin (an anticoagulant) .3 ml (mililiter) via subcutaneous injections every 12 hours for 21 days. In addition, the resident was to receive the antibiotic,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interviews, the facility failed to ensure respiratory equipment was maintained per professional standards for 3 of 3 residents reviewed for respiratory care. (Resident 44, 33 and 1 ) Findings include: 1. Resident 44 was observed on 6/12/2023 during the initial tour of the facility, lying in bed, holding his oxygen tubing and nasal cannula in his hands. The resident's oxygen tubing, which was connected to a concentrator was not dated and there was no plastic storage bag observed in the room. On 6/13/23 at 10:07 A.M., Resident 44 was observed seated in his wheelchair with oxygen per a nasal cannula connected to a portable oxygen tank. The tubing was not dated. On 6/16/23 at 9:30 A.M., Resident 44 was observed lying in bed. The resident was not wearing oxygen at the time. The oxygen tubing was hanging off the back of his wheelchair, connected to a portable oxygen tank. There was no storage bag noted and the oxygen tubing was not dated. A record review was completed on 6/16/23 for Resident 44. Diagnoses included, but not limited to: dementia,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents by 1 of 2 medication carts, 1 of 3 treatment carts. Findings include: 1. During a medication observation, on 6/14/2023, at 8:20 A.M., Qualified Medication Aide (QMA) 8 left the medication cart unlocked while she was in a resident's room. The medication cart was not in view of the QMA. QMA 8 indicated she should have locked the cart before entering the resident's room. 2. During a medication observation, on 6/14/2023 at 2:45 P.M., Licensed Practical Nurse (LPN) 9 walked away from the medication cart without locking it. It was not in view of the LPN. LPN 9 indicated he should have locked the medication cart before walking away. 3. On 6/15/2023 at 8:08 A.M., during an observation and interview with QMA 17, the treatment cart was unlocked in the unit's resident lounge with treatment medications and supplies. QMA 17 indicated the cart should be locked. 4. During a medication observation, on 6/15/2023 at 11:56 A.M., Registered Nurse (RN) 11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.