The Cardinal at North Hills

In the surveyor’s words

From the most serious findings on record at The Cardinal at North Hills, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 21, 2023

  Based on staff interviews, interview with the Medical Director, and record review, the facility failed to safely transfer a dependent resident from bed to wheelchair using a mechanical lift. On 6/13/23 during a transfer by Nurse Aide (NA) #1, the resident (Resident #6) fell out of the lift and onto the floor resulting in a cervical (neck) fracture of the first and second cervical vertebrae. Resident #6 required a cervical collar (used to support the neck and spine and limit head movement after an injury) and no surgical intervention for the injury. This deficient practice affected 1 of 1 resident reviewed for accidents. Findings included: Resident #6 was admitted to the facility on [DATE]. Diagnosis included, in part, Alzheimer's Disease. […]

• No harm, potential for more than minimal, widespreadF812Sep 10, 2025

  Based on observation and staff interviews, the facility failed to label, and date repackaged and opened food items in 2 of 2 reach-in freezers and on a preparation station. This deficient practice had the potential to affect food served to residents. The findings included:On 9/8/2025 at 11:02 AM an initial tour of the free standing second-floor kitchen included Dietary Aide #1, Administrator, and Executive Chef. The second-floor kitchen was used to serve residents on that floor, and the tour revealed several food items stored in the reach-in freezer ready for use without an open date. a. On 9/8/25 at 11:31 AM the following were observed in reach-in freezer #1 not labeled with an open date:Two bags of carrots stored in plastic zipped bags. […]

• No harm, potential for more than minimal, widespreadF851Sep 21, 2023

  Based on staff interview and record review, the facility failed to successfully submit payroll data to the Centers for Medicare and Medicaid Services (CMS) and failed to follow up that the information submitted on the Payroll Based Journal (PBJ) report was accepted by CMS. Findings included: The CMS Submission Report, PBJ Final File Validation Report was reviewed for Fiscal Year Quarter 3, 2023 (April 1-June 30). The report indicated PBJ data for Quarter 3, 2023, was submitted on 8/13/23 at 8:10 PM. Further review of the report revealed the entire file was rejected by CMS. […]

• No harm, potential for more than minimal, patternF727Jul 27, 2022

  Based on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 13 of 206 days reviewed from 1/1/22 through 7/25/22 for staffing. Findings Included: A review of the facility ' s staffing sheets revealed no RN coverage for 01/22/2022, 01/23/2022, 2/12/22, 2/13/22, 2/26/22, 2/27/22, 3/12/22, 3/13/22, 3/20/22, 3/26/22, 3/27/22, 7/23/22, and 7/24/22. During an interview with the Director of Nursing on 7/27/22 at 3:55 PM, she stated she does the nursing schedule and on 01/22/2022, 01/23/2022, 2/12/22, 2/13/22, 2/26/22, 2/27/22, 3/12/22, 3/13/22, 3/20/22, 3/26/22, 3/27/22, 7/23/22, and 7/24/22 there was no RN coverage. The DON stated she reached out to staff for coverage and tried to get a RN from staffing agencies. […]

• No harm, potential for more than minimal, isolatedF609Sep 10, 2025

  Based on record review and staff interviews, the facility failed to report an allegation of injury of unknown origin to local law enforcement and Adult Protective Services (APS) for Resident #3 and also failed to complete the Investigation Report within the required five-day time frame to the State Agency (SA) for 1 of 1 resident reviewed for injury of unknown origin (Resident #3).The findings included:Resident #3 was admitted to the facility on [DATE] with diagnoses including dementia, hypertension, arthritis, and a history of kidney stones.The admission Minimum Data Set (MDS) on 1/15/2025, revealed Resident #3 required full assistance with showering, bathing, and other daily activities. The resident was not able to complete the interview to assess cognitive patterns. […]