Cardinal Woods Skilled Nursing & Rehab Ctr

Inspectors wroteBased on record review, facility self-reported incident (SRI) review and investigation, interviews and facility policy review, the facility failed to protect Resident #96's right to be free from physical abuse by another resident. Actual harm occurred on 06/23/26 when Resident #96 sustained a fall after being struck by Resident #87 resulting in rib fractures requiring hospitalization and treatment for a pneumothorax (collapsed lung). Resident #96 remained hospitalized through 07/01/26 and then was discharged to a different facility at the request of his family. This affected one (Resident #96) of three residents reviewed for abuse. The facility census was 95.

Inspectors wroteBased on record review, review of the facility self-reported incident investigation, interviews and review of facility policy, the facility failed to conduct a complete and thorough investigation for an allegation of resident-to resident physical abuse. This affected one (Resident #96) of three residents reviewed for abuse. The facility census was 95.

Inspectors wroteBased on medical record review, observations, interviews, and policy review, the facility failed to implement a comprehensive, individualized, and effective nutrition program to prevent and address significant resident weight loss. Actual harm occurred on 03/20/26 when the facility identified Resident #75 experienced an unplanned significant weight loss of 22.6 percent (%) in approximately one month, and failed to implement appropriate interventions, provide continued monitoring of the resident's weight, or notify the physician of concerns. Subsequently, Resident #75 experienced a second unplanned weight loss of 6.82% approximately two months later. In total, Resident #75 experienced a significant weight loss of 27.8% in approximately three months. This affected one (#75) of three residents reviewed for nutrition. The facility census was 89.

Inspectors wroteBased on observation, staff interview, review of maintenance records and review of facility policy, the facility failed to ensure foods were stored and served at appropriate temperatures to prevent foodborne illnesses. Additionally, the facility failed to ensure kitchen equipment was maintained in a clean and sanitary manner. This had the potential to affect all 89 residents in the facility who were identified to receive food from the kitchen. The facility census was 89.

Inspectors wroteBased on medical record review, staff interview and review of the facility policy, the facility failed to ensure comprehensive care plans were developed and updated to address resident care needs. This affected one (#75) of three residents reviewed for care planning. The facility census was 89.

Inspectors wroteBased on closed medical record review, staff interview and review of facility policy, the facility failed to ensure fall interventions were implemented. This affected one (#98) of four residents reviewed for falls. The facility census was 89.

Inspectors wroteBased on record review, review of facility Self-Reported Incidents (SRI), review of local law enforcement reports, interviews and facility policy review, the facility failed to protect Resident #71's right to be free from abuse by Resident #93 and failed to protect Resident #64's right to be free from abuse by Resident #88. This affected two residents (#71 and #64) of four residents reviewed for abuse. Actual Harm occurred on 11/13/25 when Resident #71 reported he had been inappropriately touched and choked by another Resident (#93). Upon assessment, Resident #71 was noted to have an abrasion to his lower neck and scratches to his left shoulder. Resident #71 complained of a sore throat and rectal tenderness. The resident's rectum was assessed to be reddened. The resident was transferred to the hospital for evaluation but subsequently declined having a rape assessment completed.

Inspectors wroteBased on record review, review of the facility self-reported incident (SRI) and investigation, review of facility policy, observation and interview, the facility failed to ensure Resident #12 was free from physical abuse by Resident #40. Actual harm occurred on 03/16/25 when Resident #40, who had known verbal and physical aggressive behaviors towards others, punched Resident #12 in the face, head, and neck approximately 20 times resulting in facial and scalp contusions, headache and neck pain requiring evaluation and treatment in the hospital emergency room (ER). Resident #12 had X-rays, and a Computed Axial Tomography (CAT) scan performed while in the ER which indicated there were no broken bones. Resident #12 was diagnosed with physical assault, head, face, and neck contusions. [...]

Inspectors wroteBased on observation, medical record review, review of the hospital records, review of the fall incident, facility policy review and family, staff and resident interview, the facility failed to ensure the physician was notified immediately of an unwitnessed fall with injury, and failed to timely update the physician on increased, severe pain and delay transferring the resident in and out of bed until further orders from the physician were obtained to prevent further injury and pain for Resident #57. Actual harm occurred beginning on 02/21/25 when Resident #57, who was severely cognitively impaired had an unwitnessed fall in his room with evidence of left foot rotation and increasing complaints of pain in his hips without timely and adequate treatment. [...]

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility Self Reported Incident (SRI) and investigation, the facility failed to ensure the misappropriation of narcotic pain medication did not occur for Resident #80. This affected one resident (Resident #80) out of six residents reviewed for misappropriation. The facility census was 94.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a baseline care plan that included instructions needed to provide effective and person-centered care for Resident #40. This affected one resident (Resident #40) out of six residents revealed for care plans. The facility census was 94.

Inspectors wroteBased on medical record review, observation, interview and policy review, the facility failed to ensure Resident #53 received medications in a timely manner. This affected one resident (#53) of four residents reviewed for medication administration. The facility census was 91.

Inspectors wroteBased on interview and observation the facility failed to ensure foods were served at a palatable temperature. This had the potential to affect 81 of the 83 residents in the facility. Two residents (#34 and #84) were identified by the facility as receiving nothing by mouth. The facility census was 83.

Inspectors wroteBased on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interview, the facility failed to provide required 48-hour notice for last covered day of therapy, failed to provide the correct last covered day, failed to provide appeal information, and did not place the resident name or identifying number on the on the NOMNC letter. This affected three residents (#342, #343 and #344) of three reviewed for liability notices. The facility census was 83.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to follow recommendations to monitor weights after a significant weight loss for Resident #65. This affected one resident (#65) of two residents reviewed for weight loss. The facility census was 83.

Inspectors wroteBased on record review and interview the facility failed to provide adequate assistance/supervision to prevent a fall with injury for Resident #58. This affected one resident (#58) of three residents reviewed for accidents. The facility census was 88. Actual Harm occurred on 06/08/24 when Resident #58, who was assessed as requiring substantial/maximal assistance with showers, was left unattended in the shower, resulting in a fall with a right hip fracture.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure residents with food allergies and/or food intolerances did not receive those foods at meals. This affected one resident (#15) out of three residents reviewed for food allergies/intolerances. The facility identified ten residents (#7, #8, #15, #41, #42, #44, #47, #60, #64, and #79) as having known food allergies. The facility census was 96.

Inspectors wroteBased on observation, interview, record review and facility policy review revealed the facility failed to ensure resident room temperatures were maintained at a comfortable level for residents and between 71 to 81 degrees Fahrenheit as required. This had the potential to affect 49 residents (#1, #2, #4, #5, #6, #7, #8, #9, #12, #13, #16, #17, #19, #20, #21, #22, #24, #29, #30, #31, #32, #34, #35, #36, #37, #39, #43, #49, #55, #56, #58, #59, #62, #64, #65, #67, #71, #73, #74, #75, #77, #78, #81, #82, #84, #85, #95, and #97) who resided on the Elmwood and [NAME] units and one additional resident (#26) who resided on the Magnolia Unit identified through interview. The facility census was 99. Findings Include: Review of the facility room temperature logs revealed the following temperatures obtained on 02/04/24, 02/05/24 and 02/06/24: On 02/04/24 at 8:00 A.M. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of an emergency medical service run report, review of hospital medical records, review of witness statements, review of a mechanical lift sling invoice, review of the mechanical lift instruction manual, review of the mechanical lift sling owner's manual, review of facility policy, and interview, the facility failed to ensure a mechanical lift and mechanical lift sling were used according to manufacturer's guidelines and failed to ensure proper mechanical lift transfer technique was used for Resident #58 to prevent a fall with injury. This affected one resident (#58) of three residents reviewed for falls. The census was 97. [...]

Inspectors wroteBased on review of the resident council meeting minutes and staff interview the facility failed to ensure resident concerns were resolved in an appropriate manner and time frame. This affected five residents (Resident's #7, #27, #37, #66, #73) who resided on the Elmwood unit, 2 Resident's (#40 and #72) who resided on the Magnolia unit and had the potential to affect all residents residing in the facility. The facility census was 88.

Inspectors wroteBased on record review, interview, and facility policy and procedure review, the facility failed to ensure all employees were checked against the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the State Nurse Aide Registry (NAR) concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property as required. This had the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on observation, interview and menu spreadsheet review, the facility failed to follow the menu as written. This affected 86 residents receiving meals from the kitchen as two residents (Resident's #31 and #70) were ordered nothing-by-mouth. The facility census was 88.

Inspectors wroteBased on observation, interview, and menu spreadsheet review, the facility failed to serve palatable meals at appetizing temperatures. This affected 86 residents receiving meals from the kitchen as two residents (Resident's #31 and #70) were ordered nothing-by-mouth. The facility census was 88.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a clean and sanitary kitchen. This affected 86 residents receiving meals from the kitchen as two residents (Resident's #31 and #70) were ordered nothing-by-mouth. The facility census was 88.

Inspectors wroteBased on observations, interviews, and record reviews, the facility administration failed to ensure its resources were effectively and efficiently managed to attain and maintain the highest practicable physical, mental, and psychosocial well-being of all 88 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection control practices during a global pandemic. This had the potential to affect all residents residing in the facility. The facility census was 88. Findings Include: 1. Observation on 06/07/22 Certified Nurse Aide (CNA) #830 was observed sitting at the nurses' station with her N95 mask below her mouth. Interview with CNA #830 said she had just lowered her mask so she could breathe. She confirmed she should be wearing her N95 mask at all times while in the patient care areas. 2. Interview with the Administrator on 06/08/22 at 3:15 P.M. revealed Resident #73 had tested positive for COVID-19. The Administrator said she was asymptomatic and does not have a roommate. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to ensure antibiotic usage was tracked for effectiveness. This had the potential to affect all residents residing in the facility. The facility census was 88. Findings Include: Review of the facility's antibiotic stewardship logs from April through June 2022 revealed they tracked the onset date of the infection, the type of infection, the antibiotic the resident was placed on, and if they were placed in isolation. No information was recorded regarding the dosage and duration of the antibiotics or if the antibiotic was to be administered orally, topically, or intravenously. No information was documented regarding if any lab work was obtained or what infection assessment tool or management algorithm was being used for tracking. [...]

Inspectors wroteBased on observations and staff interview the facility failed to maintain a clean, functional, and well-maintained environment. This affected 22 residents (Resident's #3, #9, #10, #12, #13, #15, #18, #19, #23, #26, #35, #36, #39, #56, #72, #75, #76, #86, #88, #89, #290, and #388) and had the potential to affect all residents residing in the facility. The facility census was 88.

Inspectors wroteBased on interview and record review the facility failed to ensure the physician was notified of physician orders not being followed and significant weight loss occurring for seven residents (Residents #24, #29, #31, #49, #53, #56, and #67) of nine residents on weekly weights. The facility census was 88. Findings Include: 1. Resident #24 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, tremors, psychosis, paranoid personality disorder, and hallucinations. Review of the physician's orders revealed on 06/08/22 the dietician added the nutritional supplement of Ensure Plus to be administered two times a day. On 06/15/22 weekly weights were ordered for Resident #24 Review of the weights for Resident #24 revealed an admission weight obtained on 03/10/22 of 205.8 pounds. [...]

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to ensure systems were in place for monitoring weights, implementing nutritional interventions to prevent avoidable weight loss, monitoring the percentage of supplements consumed, assessing weight loss, assessing residents for use of adaptive equipment, assisting residents with eating, notifying the physician of severe avoidable weight loss, and providing palatable food for the residents. This resulted in severe avoidable weight loss affecting five residents (Resident's #24, #29, #49, #53, and #56) of eight residents reviewed for nutrition. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed foods were prepared to the appropriate consistency. This affected eight residents (Resident's #6, #8, #12, #18, #29, #53, #60, #68 and #73) receiving a pureed diet. The facility census was 88 residents.

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to ensure dignity was respected regarding Foley catheter use. This affected one (Resident #81) of four residents (Residents #67, #29, #77, #81) reviewed for Foley catheters. The facility census was 88.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Advanced Beneficiary Notice (ABN) was issued as required for Resident #89. This affected one (Resident #89) of three (Resident's #85, #89 and #900) reviewed for beneficiary notices. The facility census was 88.

Inspectors wroteBased on interview, record review, facility policy review, and review of facility Self-Reported Incident (SRI) #222577, the facility failed to timely report to the State Agency an allegation of abuse involving Resident's #3 and #49 as required. This affected two (Resident's #3 and #49) and had the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on interview, record review and facility policy review the facility failed to ensure the care plans for Resident's #72 and #76 were comprehensive to include respiratory care and management. This affected two (Residents #72 and #76) reviewed for respiratory care. The facility reported 15 (Resident's #3, #10, #28, #31, #35, #56, #58, #59, #62, #63, #70, #72, #75, #76 and #85) who received respiratory care. The facility census was 88.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure weekly weights were obtained per physician orders for three residents (Resident's #29, #31, #67) of nine residents reviewed for weekly weights. The facility census was 88.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing was changed and dated per acceptable standards of nursing practice for Resident's #72 and #76. This affected two (Resident's #72 and #76) reviewed for respiratory care. The facility reported 15 (Resident's #3, #10, #28, #31, #35, #56, #58, #59, #62, #63, #70, #72, #75, #76 and #85) who received oxygen therapy. The facility census was 88.