Cardinal Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 30, 2023

  Based on observation, interviews and record review, the facility failed to protect a resident's right to be free from physical abuse when a Qualified Medication Aide (QMA) pushed a resident to the ground, resulting in a fracture to the intertrochanter (hip) and radius (arm) for 1 of 3 residents reviewed for abuse. (Resident D) The immediate jeopardy began, on 12/29/22 at 7:30 P.M., when Resident D was observed being pushed to the ground by Qualified Medication Aide T, on the facility's video surveillance system. The Administrator was notified of the immediate jeopardy on 1/25/23 at 4:45 P.M. Finding includes: On 1/24/23 at 4:05 P.M., the Executive Director (ED) provided a recorded video dated 12/29/22, of the area near and around the first floor 2 E Nurses Station. […]

• Actual harm, isolatedF697Jan 30, 2023

  Based on observation, interviews and record review, the facility failed to ensure pain management was in place for a resident who sustained injuries following an altercation with a facility Qualified Medication Aide (QMA) when the resident was pushed to the ground and sustained a fracture to the hip and arm. (Resident D) Finding includes: On 1/24/23 at 4:05 P.M., the Executive Director (ED) provided a recorded video dated 12/29/22, of the area near and around the first floor 2 E Nurses Station. The Video indicated Resident D was at the Nurses Station attempting to approach the Medication Cart. QMA T was observed talking to the resident and pointing to the medication cart. When Resident D approached the medication cart again, QMA T pushed the resident causing him to fall to the floor. […]

• No harm, potential for more than minimal, patternF812Jun 19, 2023

  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. […]

• No harm, potential for more than minimal, patternF812Feb 21, 2022

  Based on observation, interview, and record review, the facility failed to ensure ungloved hands did not touch prepared foods prior to serving, failed to ensure serving scoops were inverted for drying, failed to ensure the plate warmer, food processor, coolers, pans, skillet were clean. Failed to ensure pantry refrigerators were clean. Failed to ensure items in the freezer were dated/labeled and enclosed after opening to prevent freezer burn in 1 of 1 kitchens. (Main Kitchen) This had the potential to affect 73 of 75 residents who received meals out of this kitchen. Findings include: 1. During a kitchen observation, on 2/14/22 from 9:52 A.M. to 10:39 A.M., the following were observed: a refrigerator floor bottom and racks were dirty with dried food substances. […]

• No harm, potential for more than minimal, patternF921Feb 21, 2022

  Based on observation, interview and record review, the facility failed to ensure a safe, clean and comfortable environment was maintained, related to a broken electrical box, a wall with a visible crack, wall and peeling paint on the ceiling, unpainted spackled areas, base board heaters with gouged/ bent metal and chipped paint, a fire door with bent door metal, and an unlocked housekeeping closet dirty with floor care mats and swivel stools. Finding includes: During an environmental tour, on 2/21/22 from 11:30 A.M. to 11:46 A.M., with the Maintenance staff, the following was observed: Room 115 had an electrical box not attached to the wall above a residents head board. A wall with a crack extending from the ceiling, half way down the wall. […]