Northern Cardinal Rehabilitation and Nursing

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF578Apr 14, 2023

  Based on interview, record review, and facility policy review, the facility failed to ensure that the facility accurately reflected the advance directive status for three of 12 sampled residents (Resident (R) 1, R73, and R109) reviewed for advance directives. Advance directive forms were not present for residents who were identified as DNR (do not resuscitate) status. Although physicians signed forms indicating code status, the forms were not signed by the resident or a health care surrogate named in an advance directive form. […]

• No harm, potential for more than minimal, patternF623Apr 14, 2023

  Based on interview, record review, and review of facility policy, the facility failed to notify the resident and/or the resident's representative, as well as the Ombudsman of transfers and the reason for the move in writing for two (Resident (R) 19 and R69) of three residents reviewed for hospitalization . The facility failed to provide a written notice, containing all required information, including the reason, date, and location to which the resident was transferred, as well as information about appeal rights, when R19 and R69 were transferred to the hospital for emergency care. Findings include: 1.Review of the Progress Note tab in R69's electronic medical record (EMR) revealed a progress note dated 09/23/22 and timed 12:23 AM. […]

• No harm, potential for more than minimal, patternF657Apr 14, 2023

  Based on resident and staff interviews, clinical record review and facility documentation review, the facility staff failed to invite 3 residents to attended their person-centered care plan and failed to update and revise one resident care plan who had a change in their code status for 4 of 57 residents (Resident #73, #63, #161 and #109) in the survey sample. PARTICIPATION IN CARE PLANNING 1. a. Review of R73's Admission Record, located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease with late onset. […]

• No harm, potential for more than minimal, patternF658Apr 14, 2023

  Based on interview, record review, and review of facility policy, the facility failed to ensure one (Resident (R) 63) of five residents reviewed for unnecessary medications received their medication in accordance with accepted professional standards. The facility failed to administer medications in a timely manner as ordered on four of four weekends that were reviewed. Findings include: Review of the Medication Administration policy, revised 12/01/22, revealed it is the facility policy to administer medications within 60 minutes prior to or after the scheduled time. On 04/14/23 at 9:30 AM, a telephone interview with R63's family member (FM63) revealed her mother called her about her medications being late on the weekends. […]

• No harm, potential for more than minimal, patternF689Apr 14, 2023

  Based on observation, interview, record review, and policy review, the facility failed to ensure that three of 57 sampled residents (Resident (R) 32, R73, and R94) were free of potential accidents while residing in the facility. Specifically, the facility failed to verify placement and function of wander guards (device worn to prevent elopements) for the three residents, who had wandering and/or exit-seeking behaviors. This failure placed the resident at risk for elopement and potential injury. In addition, the facility failed to thoroughly assess one resident (R211) after a fall, as well as conduct a thorough investigation with a root cause analysis to determine the reason for the resident's fall so as to initiate steps to prevent further accidents. Findings include: 1. […]