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Inspection visit

Health inspection

CARDINAL WOODS SKILLED NURSING & REHAB CTRCMS #3656581 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. 37 residents (32 rooms) had room temperatures below 71.0 degrees F: room [ROOM NUMBER] - 66.6 degrees F room [ROOM NUMBER] - 66.2 degrees F room [ROOM NUMBER] - 66.4 degrees F room [ROOM NUMBER] - 65.7 degrees F room [ROOM NUMBER] - 65.3 degrees F room [ROOM NUMBER] - 62.8 degrees F room [ROOM NUMBER] - 63.7 degrees F room [ROOM NUMBER] - 61.5 degrees F room [ROOM NUMBER] - 69.3 degrees F room [ROOM NUMBER] - 66.4 degrees F room [ROOM NUMBER] - 67.6 degrees F (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365658 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584 room [ROOM NUMBER] - 67.3 degrees F Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER] - 68.5 degrees F room [ROOM NUMBER] - 68.5 degrees F Residents Affected - Some room [ROOM NUMBER] - 65.1 degrees F room [ROOM NUMBER] - 64.4 degrees F room [ROOM NUMBER] - 65.8 degrees F room [ROOM NUMBER] - 65.3 degrees F room [ROOM NUMBER] - 68.9 degrees F room [ROOM NUMBER] - 68.3 degrees F room [ROOM NUMBER] - 68.5 degrees F room [ROOM NUMBER] - 66.0 degrees F room [ROOM NUMBER] - 67.2 degrees F room [ROOM NUMBER] - 68.7 degrees F room [ROOM NUMBER] - 69.6 degrees F room [ROOM NUMBER] - 66.7 degrees F room [ROOM NUMBER] - 69.0 degrees F room [ROOM NUMBER] - 67.4 degrees F room [ROOM NUMBER] - 68.3 degrees F room [ROOM NUMBER] - 68.3 degrees F room [ROOM NUMBER] - 68.0 degrees F room [ROOM NUMBER] - 69.0 degrees F room [ROOM NUMBER] - 67.8 degrees F On 02/05/24 temperatures taken at 1:00 P.M. revealed eight resident rooms were below 71 degrees F: room [ROOM NUMBER] - 68.8 degrees F room [ROOM NUMBER] - 70.5 degrees F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584 room [ROOM NUMBER] - 70.0 degrees F Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER] - 70.3 degrees F room [ROOM NUMBER] - 70.0 degrees F Residents Affected - Some room [ROOM NUMBER] - 70.9 degrees F room [ROOM NUMBER] - 69.6 degrees F room [ROOM NUMBER] - 69.3 degrees F On 02/06/24 temperatures taken at 8:30 A.M. revealed two resident rooms were below 71 degrees F: room [ROOM NUMBER] - 68.0 degrees F room [ROOM NUMBER] - 68.0 degrees F Interview on 02/06/24 at 12:50 P.M. with Interim Administrator #300 and Travel Director of Nursing (DON) #301 revealed in the older parts of the building there were registers that ran on a boiler system. The facility had identified an issue with these boilers approximately three to four weeks ago. The facility had repairs made but still had an air exchanger they were waiting on a part for. Interviews on 02/06/24 at 1:20 P.M. and 1:57 P.M. with Regional Maintenance Director #308 revealed the facility had a heat problem for the last three to four weeks. One boiler was working fine. The problem was with the air exchangers. There was one working now and they received quotes on the second one. They had been in contact with the company to get it fixed but had been unable to get the parts to fix it. The facility brought in four portable heat pumps. Interview on 02/06/24 at 3:31 P.M. with Resident #26, who resided on the Magnolia unit, stated her room was cold last night, and staff got her another blanket. The resident had a PTAC unit (individual heating unit) that broke, and she was moved to another room on the Magnolia unit. Interviews on 02/06/24 from 3:33 P.M. through 4:45 P.M. with residents from the [NAME] and Elmwood units revealed five residents, Resident #8 #16, #21, #22, and #77 voiced concerns with room temperatures/heat and indicated they felt their rooms were cold at night. On 02/07/24 from 7:45 A.M. through 7:56 A.M. observations of the resident room temperatures revealed two rooms on the Elmwood and [NAME] units were below 71 degrees F, the temperature in room [ROOM NUMBER] was 68.9 degrees F, and the temperature in room [ROOM NUMBER] was 69.4 degrees F. Interview on 02/07/24 at 11:38 A.M. with the Administrator verified the room temperature logs and temperatures taken during the survey identified resident room temperatures had not been maintained between 71 and 81 degrees Fahrenheit as required. Review of the facility undated policy and procedure for Extreme Cold Temperature defined optimal internal environment temperature range: (as defined by CMS) 71 degrees F and 81 degrees F. The policy revealed the facility would provide a safe, clean and comfortable and homelike environment including a comfortable and safe regulated temperature range of 71 degrees to 81 degrees within the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584 Level of Harm - Minimal harm or potential for actual harm The policy included this ambient air temperature range minimized resident's susceptibility to loss of body heat and risk of hypothermia or hyperthermia and provides a comfortable homelike setting. This deficiency represents non-compliance investigated under Complaint Number OH00150821. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 4 of 4

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0584GeneralS&S Epotential for harm

    F584 - Safe Environment

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

FAQ · About this visit

Common questions about this visit

What happened during the February 7, 2024 survey of CARDINAL WOODS SKILLED NURSING & REHAB CTR?

This was a inspection survey of CARDINAL WOODS SKILLED NURSING & REHAB CTR on February 7, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CARDINAL WOODS SKILLED NURSING & REHAB CTR on February 7, 2024?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.