Cardinal Care of Jacksonville

The facility failed to ensure a resident was referred to a dermatologist as ordered by his primary care provider. Although a referral was faxed, the facility did not follow up effectively regarding insurance issues or notify the resident's guardian, resulting in the specialist visit not being completed.

The facility failed to administer medications in accordance with orders and facility policies, specifically regarding the crushing of medications. During medication passes, staff crushed Toprol-XL and Prilosec for Resident #5, despite explicit instructions in the resident's record and pharmacy labels stating 'do not crush.' This resulted in a medication error rate of 12% during the observed period.

The facility failed to ensure that one of three sampled staff members had no substantiated findings listed on the North Carolina Health Care Personnel Registry (HCPR) upon hire. Specifically, there was no documentation of an HCPR check in the personnel record for a personal care aide hired on 04/16/20.

The provided text identifies the regulation regarding the administrator's responsibility for the total operation of the home and maintaining rules, but the specific deficiency details/findings for this tag were not included in the provided text snippet.

The facility failed to ensure that therapeutic diets, specifically nectar-thickened liquids, were served as ordered by the resident's physician. Observations of Resident #3 revealed that beverages, including water and tea, were served with a thin, watery consistency rather than the required nectar-thick consistency. Staff members were found to be using incorrect measurements and unmeasured amounts of liquid when preparing thickened beverages.

The facility failed to ensure that therapeutic diets, specifically nectar-thickened liquids, were served as ordered by the resident's physician. Observations of Resident #3 revealed that beverages, including water and tea, were served with a loose consistency similar to water rather than the required nectar-thick consistency. Interviews with staff indicated improper preparation methods and a lack of precise measurement during the thickening process.

The facility failed to maintain clean and well-repaired walls, floors, and ceilings. Specific issues included exposed nails in resident rooms, unaligned and stained emergency exit doors, and various stained or damaged floor tiles and wall surfaces in hallways and bedrooms.

The facility failed to maintain walls, ceilings, and floors in a clean and good state of repair. Specific issues included dusty ventilation grates, exposed protruding nails in resident rooms, misaligned and stained emergency exit doors, and stained or damaged flooring in hallways and bathrooms.