Cardinal Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Cardinal Healthcare and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Mar 22, 2022

  Based on record review, staff interviews, Nurse Practitioner (NP) and Medical Director interviews, the facility failed to notify the Physician or Nurse Practitioner of Resident #1 being on anticoagulant therapy when he had experienced an unwitnessed fall with a head injury. The facility also failed to notify the Physician or NP when Resident #1 experienced a change of condition after a fall with head injury by becoming increasingly confused, not urinating for the entire day, and having no intake by mouth. This was for 1 of 3 residents reviewed for notification (Resident #1). […]

• Immediate jeopardy, isolatedF684Mar 22, 2022

  Based on record review and staff, Nurse Practitioner (NP) and Medical Director interviews, the facility failed to complete and document on-going thorough assessments of a resident's condition who was prescribed an anticoagulant and had an unwitnessed fall with a head injury. In addition, Nurse Aide #2 observed the resident was moaning, had not eaten breakfast and lunch, and had not voided but did not report this to the nurse until later in the day. This was for 1 of 3 residents reviewed for quality of care (Resident #1). Resident #1 was transferred to the hospital for an evaluation and found to have a C6 (part of the cervical spinal cord, located in the lowest region of the neck) vertebral fracture. […]

• Actual harm, isolatedF550Oct 28, 2021

  Based on observation, record reviews, staff interviews, and resident interviews the facility failed to maintain residents' dignity by delaying incontinence care affecting 1 of 1 resident (Resident #26) reviewed for dignity. The resident expressed feelings of being uncomfortable, upset, mad and embarrassed. The findings included: 1.Resident #26 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact and dependent upon staff members for assistance with toilet use and transfers. Resident #26 was coded as being incontinent of bowel and bladder. Resident #26 was coded as having adequate vision. […]

• Actual harm, isolatedF697Oct 28, 2021

  Based on observations, record reviews, resident, staff, and Physician's Assistant (PA) interviews, the facility failed to manage a resident's complaints of pain for 1 of 2 residents (Resident #46) reviewed for pain management. The findings included: Resident #46 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During the resident's hospitalization from [DATE] to 09/20/21 she had an above the knee amputation (AKA) of the right leg. Resident #46's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired for daily decision making but could make her needs known. […]

• Actual harm, isolatedF725Oct 28, 2021

  Based on observations, record reviews, resident, and staff interviews, the facility failed to provide sufficient nursing staff for the provision of incontinence care to a resident (Resident #26) who had a bowel movement, failed to provide showers as scheduled for 1 resident (Resident #23) and failed to provide showers or complete bed baths for 1 dependent resident (Resident #46). This affected 3 of 7 residents reviewed for sufficient nursing staff. The findings included: This tag is cross referred to: F550: Based on observation, record reviews, staff interviews, and resident interviews the facility failed to maintain residents' dignity by delaying incontinence care affecting 1 of 1 sampled resident (Resident #26). […]