Every finding on record at The Cardinal at North Hills

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. Shaved coconut in a plastic zipped bag.Three plastic zipped bags containing chicken tenders. One opened bag of hamburger sliders stored in a plastic zipped bag. On 9/8/2025 at 11:44 AM Administrator advised Dietary Aide #1 to throw the items, without a date in reach-in freezer #1 into the trash. On 9/8/2025 at 11:49 AM the Executive Chef stated the food items should have been dated. An additional observation of reach-freezer #1 on 9/10/25 at 11:15 AM with Dietary Aide #2 present revealed an opened bag of frozen potato chips without an open date. Dietary Aide #2 was interviewed during the observation and stated the bag was recently opened. Dietary Aide #2 stated she opened them because they were serving them for lunch. She stated that she should have dated the bag when she opened them. On 9/10/25 at 11:25 AM the Administrator instructed Dietary Aide #2 to throw the remaining frozen potato chips away and to throw away the cooked chips in the deep fryer. The Administrator instructed the Dietary Aide to get a new unopened bag from first floor kitchen. On 9/10/25 at 12:00 PM an interview with Dietary Aide #2 revealed she was disappointed she forgot to date the frozen potato chips. She stated it was one of her responsibilities to make sure opened items in the freezer were dated. b. On 9/8/25 at 11:37 AM an observation of reach-in freezer #2 occurred with Dietary Aid #1 and the Administrator revealed two opened 5-gallon buckets of ice cream that were not dated when opened.c. On 9/8/25 at 11:41 AM observation of a kitchen preparation station with the Administrator and Executive Chef present revealed two plastic grocery bags that were tied shut containing thick sliced bread that was heavily buttered with no open date. Executive Chef stated during the observation it was going to be served that day.On 9/8/25 at 11:43 AM the Administrator instructed Executive Chef to throw the bread away. Interview with the Executive Chef on 9/10/2025 at 3:11 PM revealed the food items in the reach-in freezers should have been dated with the date the item was opened. The Executive Chef indicated he worked primarily in the first-floor kitchen, and the second-floor kitchen was run primarily by the Dietary Aides. He stated that staff were trained to label food items with an open date before storing them in the freezer. On 9/10/2025 at 4:00 PM interview with the Administrator revealed the kitchen staff should have dated any food that was opened and stored in the freezer. He stated he understood that the food was often removed from its original container and sent up to the second-floor kitchen from the first-floor kitchen, but staff should still make sure they label and date.

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. The Staff Assessment for Mental Status determined that Resident #3 had long-term and short-term memory impairment and had severely impaired cognitive skills for daily decision making. The Initial Allegation Report submitted by the facility for an injury of unknown origin dated 01/30/2025 was completed by the previous Administrator. The report indicated that on 1/30/2025 around 7:45 AM to 8:00 AM, Nurse Aide (NA) #1 found the resident had six unidentified markings on her inner right forearm. The markings/skin tears were described as open, red and bloody. The affected areas were evaluated by the Nurse #1 on 01/30/2025, and the markings/skin tears were cleaned, and patched with appropriate dressings. The report did not include evidence that local law enforcement or Adult Protective Services (APS) had been notified, as required.Nurse Aide #1's written statement dated 1/30/25 indicated on 1/30/25 at 7:50am Nurse Aide #1 went into Resident #3's to provide care. As Nurse Aide #1 began to give care, six skin tears were found on Resident #3's upper right arm. The unidentified skin tears on the inner right forearm were open cuts that were described as red, and bloody in appearance. Nurse Aide #1 indicated that resident #3 was unable to get out of bed without assistance. Nurse Aide #1 also indicated that at 7:55am, Nurse #1 was notified of the injury. The affected areas were reportedly evaluated by the Nurse #1, cleaned, and patched with appropriate dressings.Nurse #1's written statement dated 1/30/25 indicated on 1/30/25 at 8:00am, Nurse Aide #1 asked Nurse #1 to observe Resident #3's right arm. Nurse #1 observed four skin tears on Resident #3's right arm and indicated that the Resident #3's fingernails had no evidence of blood, and the sleeping area contained no objects that could have caused injury. The statement also noted that Nurse #1 notified the previous Administrator. A telephone interview with NA #1 was attempted on 09/09/2025 at 1:50 PM but was not successful. A telephone interview with Nurse #1 was attempted on 09/09/2025 at 1:55 PM but was not successful. There was no evidence that an Investigation Report was submitted for Resident #3's injury of unknown origin.On 09/09/2025 at 1:21 PM, an attempt was made to contact Resident #3's responsible party (RP) regarding the incident. There was no response to the voice mail that was left requesting a return call.On 09/09/2025 at 1:26 PM, Resident #3's arms were observed. No signs of bruising or open wounds were noted. An attempt was made to interview Resident #3 regarding the injuries during the observation and Resident #3 was unable to provide information about the incident. An interview was completed with the Director of Nursing (DON) on 09/10/2025 at 2:13 PM. The DON revealed that she was not aware of the injury of unknown origin involving Resident #3, as she had only recently been hired. The DON further revealed that she could not obtain additional information because NA #1 and Nurse #1 were no longer employed at the facility, and their contact information was unavailable. An interview with the Social Worker (SW) on 09/10/2025 at 2:45 PM revealed that she was unaware of the injury of unknown origin involving Resident #3, explaining that she works at the facility only on Wednesdays. She explained that she typically received reports of alleged abuse from the DON or Administrator, and her role in the allegation was to interview residents who were alert and oriented, as well as any individuals involved. The SW indicated final reporting decisions were made by the DON or Administrator.During an interview on 09/09/2025 at 1:59 PM, the Administrator revealed that he was not aware of the injury of unknown origin involving Resident #3, as he had recently been hired. He confirmed that the Administrator in place at the time of the injury was no longer employed at the facility and her contact information was unavailable. The Administrator was unable to explain why the Investigation Report for the injury of unknown origin was not available for review, why APS and local law enforcement had not been notified, or why he was unable to locate any of the facility's abuse Investigation Reports. He stated that allegations of abuse were required to be reported to the State Agency within 24 hours, with the Investigation Report submitted within five days.

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. A physician (MD) order dated 12/16/20 stated a mechanical lift was to be used for transfers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had no speech and was rarely understood by others. She exhibited impaired memory and her daily decision making skills were severely impaired. She required extensive assistance with the help of two people for transfers. The MDS further indicated Resident #6 was not on an anti-coagulant medication. The care plan, updated 5/26/23, included a focus area of risk for falls. Care plan interventions stated, Review information on past falls and attempt to determine cause of falls, record possible root causes and educate resident/family/caregivers as to causes. The NA Care Kardex, located at the nurse's desk was reviewed and stated Resident #6 required a mechanical lift for transfers and needed two staff members to complete bed mobility and mechanical lift transfers. An Incident Report dated 6/13/23 and completed by the Staff Development Nurse stated the following: At 7:19 AM on 6/13/23 the resident had a fall in her room while she was being transferred from bed to wheelchair from the mechanical lift. NA #1 was present during the incident. The report further stated Resident #6 was transported to the hospital by Emergency Medical Services (EMS) and the MD and family member were notified. Resident #6 returned to the facility on [DATE] with a cervical collar. NA #1 was removed from the floor during the investigation and was no longer employed at the facility. An emergency department note dated 6/13/23 stated, in part, Resident #6 presented to the ED with reports of a mechanical fall. Patient is non-verbal, typically bedbound (although gets up in a wheelchair for a few hours each day) and has contracted extremities .Family arrived shortly after patient did and is able to provide some further history that the patient is not on anticoagulants. She confirmed that Resident #6 was at her baseline mental and physical status. The note further indicated a review of systems was limited since Resident #6 had dementia and was non-verbal. An assessment of Resident #6's neck in the ED revealed a cervical collar was in place and the resident winces with midline palpation. A computerized tomography (CT) cervical spine scan was completed on 6/13/23 and revealed a closed nondisplaced fracture of the first and second cervical vertebrae. According to the ED note, there was no acute, life-threatening, or emergently surgical condition identified after evaluation. Resident #6 was sent back to the facility on [DATE] with a cervical collar and a recommendation to follow up with her primary care provider within one week. A MD order dated 6/14/23 revealed, Hydrocodone/acetaminophen 7.5 milligrams (mg)/325mg every six hours. The medication was discontinued on 9/6/23. A MD order dated 7/19/23 revealed the cervical collar was to be discontinued. The quarterly MDS assessment dated [DATE] revealed Resident #6 had no speech and was rarely understood by others. She exhibited impaired memory and her daily decision making skills were severely impaired. She required extensive assistance with the help of two people for transfers. A staff assessment of pain indicated the resident did not have any non-verbal indicators of pain. Attempts to interview NA #1 by telephone were unsuccessful. In an interview with NA #2 on 9/21/23 at 11:33 AM, she explained she looked at a resident's paper chart or the CNA Kardex book for their transfer status or received the information during shift report. NA #2 had worked with Resident #6 in the past and stated her transfer status was a mechanical lift. She further explained two staff were required to operate the mechanical lift and this had always been the protocol for mechanical lift transfers for every resident in the facility. Interviews were conducted with Nurse #1 on 9/20/23 at 9:18 AM and 11:32 AM. She was at the nurse's desk when Resident #6 fell . She recalled NA #1 came out of Resident #6's room and told her the resident fell . Nurse #1 said she went to Resident #6's room, entered and saw the resident on the floor at the foot of the bed. Nurse #1 observed the mechanical lift positioned behind Resident #6's feet. Nurse #1 stated NA #1 told her the resident had fallen from the lift. Nurse #1 reported she immediately assessed Resident #6, obtained vital signs and called 911. She added the resident had not appeared to be in distress during the assessment. She explained information about a resident's transfer status was in the Kardex book located at the nurse's desk and titled CNA Care Kardex. Additionally, nurses also told staff what the transfer status was for each resident. She added if a mechanical lift was required for transfers there needed to be two staff who assisted with the transfer. Nurse #1 stated there were other staff members on the hall that day (NAs and nurses) who could have helped NA #1 with the transfer. She revealed Resident #6 returned from the emergency department with a neck collar and an order for pain medication. She said she had not observed Resident #6 with any non-verbal indicators of pain or discomfort following the fall and return from the emergency department. She added Resident #6 had not fidgeted with the cervical collar, and added, at times, Resident #6's family member removed the collar when she visited the resident. Nurse #1 shared the resident's typical routine prior to her fall was to get up in the morning for breakfast (ate in her room) and then was put back to bed after breakfast where she remained the rest of the day. Nurse #1 said she had not observed a disruption in Resident #6's normal routine when she wore the cervical collar. A review of pain assessments from 6/13/23-9/20/23 revealed Resident #6 did not display any non-verbal indicators of pain. During an interview with Occupational Therapist (OT) #1 on 9/20/23 at 9:42 AM, she stated the therapy department determined the safest method of transfer for a resident and made recommendations. She explained Resident #6 was totally dependent on staff for care and was unable to follow directions. OT #1 added the resident had always needed a mechanical lift for transfers since her admission to the facility and said two staff members were required to operate the mechanical lift. On 9/19/23 at 4:23 PM an interview was conducted with the Staff Development Nurse who stated when she came to the facility on [DATE] she was told Resident #6 was being sent out to the hospital. The Staff Development Nurse immediately went to the floor where Nurse #1 told her NA #1 used the mechanical lift by herself and dropped Resident #6 on the floor. The Staff Development Nurse said she went down to the resident's room and observed NA #1 behind the mechanical lift. Resident #6 was on the floor and both feet were over the leg of the mechanical lift. She said the resident's head was on the floor and she was on her back. The Staff Development Nurse explained that nursing staff were educated during orientation to use two people to transfer with a mechanical lift and that NA #1 knew there needed to be two staff members when Resident #6 was transferred with the mechanical lift. A joint interview was conducted with the Director of Nursing (DON) and Staff Development Nurse on 9/21/23 at 11:42 AM. The DON shared the facility protocol was whenever a resident needed a mechanical lift for transfers it required two staff members to operate the lift. She added Resident #6 was assessed as needing a mechanical lift for all transfers. She stated no other staff member witnessed Resident #6's fall from the mechanical lift. The DON said she interviewed NA #1 as part of the fall investigation and when she asked NA #1 why she had not used a second person to assist with the mechanical lift, NA #1 told her she had forgot to get a second person. The DON added NA #1 told her she normally did not operate the mechanical lift by herself and had not felt rushed when she provided care to Resident #6. The DON stated there were three other NAs and two nurses who could have helped NA #1 with the transfer that morning. She explained after the fall, all staff members were re-educated that two staff members were required when using a mechanical lift. In an interview with the Medical Director on 9/20/23 at 9:34 AM, he shared Resident #6 had end stage dementia and was non-verbal. She required total assistance with all her care. He stated he was informed by staff that one NA attempted to transfer the resident with a mechanical lift and she fell from the lift and sustained a non-displaced cervical fracture. The Medical Director further stated it was important that two staff members operated a mechanical lift to prevent falls and injuries for both residents and staff members.

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. The noted reason for rejection in the message column of the report stated, A value submitted for employee identification in the Staffing Hours section must match an existing value for employee identification in the PBJ system. If a match cannot be found, the PBJ submission will be rejected. An interview was conducted with the Executive Director on 9/20/23 at 2:02 PM. He shared he was responsible for submitting PBJ data to CMS and submitted the data once a quarter. He stated PBJ data was not correctly submitted for the past 3 submissions (each submission covered 90 days). He acknowledged there was some confusion on how data was submitted to CMS. He explained the Human Resources department sent all labor data to the home office who then compiled zip files. Once the zip files were completed, the Executive Director sent them to CMS. He explained he submitted the data on time but on the first 2 submissions we were missing a zero on the facility identification number (ID) and therefore CMS did not accept the data. The Executive Director added he didn't know he was supposed to go into the PBJ system within 48 hours to verify the data was received and accepted. He said the PBJ site notified him what the error was with the submissions. The third time he submitted data he learned the employee ID numbers were different than what was in the CMS system and the home office representative was on vacation and could not update the employee ID numbers.

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. She stated she was aware of the requirement to provide an RN for 8 consecutive hours each day and we did the best we could to get coverage.

Based on record review and staff interview, the facility failed to review care plans for 1 of 5 residents (Resident #11) reviewed for unnecessary medications. Findings Included: Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11 was care planned for being dependent for meeting emotional, intellectual, physical, and social needs, communication problem, impaired cognitive function, risk for falls and use of [CONDITION(S)] medications. All care plans were last updated 2/28/22. Record review revealed a care conference had been conducted regarding Resident #11 on 3/9/22. A quarterly Minimum Data Set (MDS) was completed on 6/1/22. Record review revealed a care conference was completed on 6/8/22. An interview was conducted with Nurse #2 on 7/27/22 at 2:00 PM and she stated she was responsible for reviewing the care plans. She stated Resident #11 ' s care plan should have been reviewed in June after she completed the MDS. She stated she just forgot.

Based on record review and staff interviews, the facility failed to implement a 14-day stop date for as needed [CONDITION(S)] medications for 2 of 2 residents reviewed for unnecessary medications, (Resident #9 and Resident # 10). Findings included: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses which included anxiety. Resident #9 ' s physician order dated 03/07/22 revealed she was ordered [MEDICATION(S)] 0.25 mg every six hours as needed (PRN) for anxiety. The order had a start date of 03/07/22 with a stop date of 03/07/2032. A review of the Medication Administration Record (MAR) for Resident #9 revealed she received [MEDICATION(S)] 0.25 mg thirteen times in March, zero times in April, one time in May, four times in June and one time in July. An interview on 07/26/22 with Nurse #2 at 11:52 am revealed she wasn ' t sure why the stop dates were not set to 14 days instead of [AGE] years. An interview with Pharmacist #1 on 07/26/22 01:27 PM revealed the computer system used for order entry automatically added a [AGE] year stop date unless someone manually added a different stop date on the order. Pharmacist #1 added the facility ' s pharmacy should have gotten clarification from the physician to ensure the PRN order of [MEDICATION(S)] had a stop date of no more than 14 days from the written date and the medication would have then fallen off Resident #9 ' s profile. An interview with the Physician on 07/26/2022 at 12:08 am revealed he was aware of the regulation for PRN [CONDITION(S)] medications to be written for no more than 14 days and Resident #9 ' s order for [MEDICATION(S)] must have been on oversight. The Physician stated the pharmacy usually alerted him if there was an order written for [CONDITION(S)] medications which did not have a stop date within 14 days after the original order was written. He stated Resident #9 ' s order should have only been written for 14 days from its original written date. 2. Resident #10 was admitted to the facility on [DATE] [CONDITION(S)]. Resident #10 ' s physician order dated 03/20/22 revealed she was ordered [MEDICATION(S)] 5mg at bedtime as needed for [CONDITION(S)]. The order had a start date of 03/20/22 with a stop date of 03/20/2032. An interview on 07/26/22 with Nurse #2 at 11:52 am revealed she wasn ' t sure why the stop dates were not set to 14 days instead of [AGE] years. An interview with Pharmacist #1 on 07/26/22 01:27 PM revealed the computer system used for order entry automatically added a [AGE] year stop date unless someone manually added a different stop date on the order. Pharmacist #1 added the facility ' s pharmacy should have gotten clarification from the physician to ensure the PRN order of [MEDICATION(S)] had a stop date of no more than 14 days from the written date and the medication would have then fallen off Resident #10 ' s profile. An interview with the Physician on 07/26/2022 at 12:08 am revealed he was aware of the regulation for PRN [CONDITION(S)] medications to be written for no more than 14 days and Resident #10 ' s order for [MEDICATION(S)] must have been on oversight. The Physician stated the pharmacy usually alerted him if there was an order written for [CONDITION(S)] medications which did not have a stop date within 14 days after the original order is written. He stated Resident #10 ' s order should have only been written for 14 days from its original written date.

Based on observation and staff interviews, the facility failed to disinfect a glucometer (used to measure a resident ' s blood glucose level) after use per the manufacturer ' s recommendation which resulted in the potential cross contamination for 1 of 1 nurse (Nurse #1) observed for medication administration. Findings included: A review of the facility ' s policy Glucometer Cleaning read in part; clean the glucometer surface after each use and when visible blood or bloody fluids are present by following the manufacturer recommended procedure, and alcohol should never be used to clean a glucometer because it can damage the glucometer. The recommended cleaning and disinfecting instructions for the meter used was reviewed. Instructions included using an Environmental Approved Agency wipe and wiping the surface of the meter to clean blood and other body fluids and dispose of wipe and then obtain a second wipe and wipe the entire surface to remove any bloodborne pathogens. The surface must remain wet for the wipes recommended contact time. The wipes used by the facility recommend a surface wet time of 4 minutes. On 7/27/22 at 9:10 AM Nurse #1 was observed obtaining a blood sugar on Resident #15 and returning to the med cart. Nurse #1 placed the glucometer on top of the medication cart and obtained an alcohol wipe. Nurse #1 picked up the glucometer and proceeded to wipe it down for less than 15 seconds. Nurse #1 placed the glucometer back on the medication cart to air dry and then placed it in a plastic box next to a second glucometer. At 9:40 AM on 7/27/22 and interview was conducted with Nurse #1, and she stated the glucometer was a multiuse glucometer and used on other residents. She stated she was told she could clean the glucometer with an alcohol wipe. An interview was conducted with Nurse #2, who is also the Infection Preventionist, and she stated Nurse #1 was trained to clean the glucometer per the manufacturer ' s instructions. She stated if the glucometer was soiled it needed to be cleaned with a manufacturer approved wipe and get another wipe to disinfect the glucometer with a contact time of 4 minutes. Nurse #2 also stated the manufacturer approved wipes are in the medication cart for cleaning the glucometers and Nurse #1 has been re-educated on the cleaning procedure. On 7/27/22 at 4:05 PM the Director of Nursing was interviewed, and she stated the glucometers should be cleaned per the manufacturer recommendations.

Based on record review, staff interviews and review of facility policy, the facility failed to administer the pneumococcal vaccine to 1 of 5 residents reviewed for immunizations, (Resident #9). Findings included: A review of the facility ' s policy dated October 2019 labeled Pneumococcal Vaccine read in part, assessments of pneumococcal vaccine status will be conducted within five (5) working days of the resident ' s admission. Administration of the pneumococcal vaccines will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. A review of the CDC recommendations dated January 24, 2022, read in part, age [AGE] years or older who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23. Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Minimum Data Set (MDS) dated [DATE] assessed Resident #9 to be severely cognitively impaired. The MDS documented the pneumococcal vaccine was not up to date. A review of the medical record for Resident #9 revealed a consent to administer pneumococcal (PVC13 and/or PPSV23) vaccine. The form was dated 03/10/2022 and signed by the resident representative and the option Yes, I wish to receive the Pneumococcal (PPSV23) vaccine of indicated was selected. The immunization record for Resident #9 was reviewed and no PPSV23 vaccine was documented as given. An interview with the Infection Preventionist (IP) on 07/25/22 at 2:18 pm revealed during Resident #9 ' s initial treatment team meeting on 03/10/22, Resident #9 ' s resident representative was asked if she wanted Resident #9 to receive the pneumococcal vaccine and she said yes. The IP stated she notified the facility ' s medical provider, about the pneumococcal vaccine request for Resident #9 but never received a response. The IP added there was no other follow up by the facility ' s medical provider regarding Resident #9 ' s need for the pneumococcal vaccine and Resident #9 never received the vaccine. The IP added there had been some communication issues with their previous medical provider and the facility had a new medical director as of 7/18/2022 and hoped the communication would work much better. An interview with the Director of Nursing (DON) on 7/20/22 at 3:47 pm revealed Resident #9 had not received the pneumococcal vaccine since admission on 03/07/2022. The DON stated her expectations would be for the physicians to have responded to the facility ' s IP ' s request regarding Resident #9 ' s pneumococcal vaccine. The DON stated Resident #9 should have received the pneumococcal vaccine.

Based on observations, record review, and staff interviews the facility failed to administer a medication according to manufacturer guidelines for 1 of 4 resident (Resident #259) observed for medication administration. Findings Included: Resident #259 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment was pending on 05/22/19. Review of resident #259's medical record revealed an order for [REDACTED]. Review of manufacturer guidelines for use of the inhaler read in part, After using the inhaler, rinse your mouth with water and spit out. Do not swallow water. On 05/21/19 at 07:52 AM observation of medication administration for resident #259 was conducted. Nurse #1 was observed to administer [MEDICATION NAME] 160/4.5 micrograms 2 puffs orally to resident #259. Nurse #1 made no attempt to have resident #259 rinse his mouth with water after administration of the medication. In an interview on 5/21/19 at 09:29 AM Nurse #1 indicated he was not aware he needed to ensure resident #259 rinsed his mouth with water after use of the inhaler. He further indicated he knew some inhalers required mouth rinsing after use but he did not think [MEDICATION NAME] was one of them. On 05/21/19 at 09:34 AM an interview with the DON revealed she was aware of the need for residents to rinse their mouth with water after use of [MEDICATION NAME] inhaler. She further indicated this was to prevent residents from suffering mouth sores or a fungal infection in their mouth from the use of a steroid inhaler. She went on to say the instruction to ensure residents rinsed their mouth with water after use of [MEDICATION NAME] was visible to the nurse administering the medication on the electronic medication administration screen at the time of administration.

Based upon observation and staff interviews, the facility failed to cover raw chicken stored in the refrigerator and failed to ensure staff wore hair and/or beard coverings in 1 of 1 kitchen used to prepare skilled nursing resident food. Findings included: 1. During a kitchen tour on 06/19/2017 with Chef #1 and Acting Food Services Director (AFSD) at 12:30 PM, Chef #1 opened the refrigerator and a metal pan of uncovered raw chicken was observed on the bottom shelf. In an interview with Chef #1 at the time of the observation, he stated he did not know why the raw chicken was uncovered, but that it should be covered. Chef #1 immediately removed the pan of chicken, covered it with plastic wrap and returned it to the refrigerator. During an interview with Chef #1 at 5:27 PM on 06/19/2017, he stated every night all opened food items were wrapped and dated and that chicken stored in the refrigerator should be covered at all times. 2. On 6/19/2017 at 11:35 AM, an observation of meal preparation in the skilled nursing facility kitchen revealed Cook #1 was preparing the lunch meal of sweet potato hash, English peas, and herb grilled chicken. Cook #1 was wearing a hair covering over his head. At 11:43 AM on 06/19/2017, the acting Food Services Director (AFSD) and the Chef entered the kitchen. The observation of the food preparation, refrigerators, dishwasher, and dry food storage area continued at 11:43 AM with the AFSD and Chef #1 present. During that time, the AFSD was not wearing a head covering or beard covering. At 12:06 PM, Server #1 entered the kitchen. Server #1 was not wearing a hair net or head covering. An observation of the kitchen at 12:06 PM revealed the dishwasher and clean food service items were located on the same side of the kitchen where Server #1 stood. The food preparation area in the kitchen was not divided by a wall; the steam table was located between the food preparation section and the area where Server #1 stood. In an interview with the AFSD and Chef #1 on 6/19/2017 at 5:27 PM, the Chef stated that the kitchen staff who prepared foods usually wore head coverings, but servers did not. He also stated that typically there was no requirement for those who entered the kitchen to wear head coverings if they stayed on the side of the kitchen where food plates were handed to the servers. Chef #1 and the AFSD stated that hair nets were ordered that day and would be used in the future for all staff who entered the kitchen. During an interview with the Administrator on 06/19/2017 at 6:10 PM, he stated that he was not aware that everyone who entered the kitchen needed to don a hair covering.