Inspection·April 11, 2024

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based 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. Findings include: Review of medical record for Resident #15 revealed an admission date of 11/29/21. Diagnoses included type two diabetes with foot ulcer, chronic systolic (congestive) heart failure, essential hypertension (high blood pressure), and unspecified protein-calorie malnutrition. Resident#15 was on a regular diet with mechanical soft/dental soft texture. Resident #15 was cognitively intact and required setup or cleanup assistance for eating. Resident #15 had a known allergen to cheese. Review of care plan, initiated 02/28/24, revealed the Resident #15 had a potential for allergic reaction with a known allergy to cheese with a goal the resident would not receive substances known to cause an allergic reaction. Observation during lunch on 04/10/24 at 12:50 P.M. revealed Resident #15, who was allergic to cheese, was served mechanical soft chicken, lima beans and au gratin potatoes. The au gratin potatoes appeared untouched. Observation of Resident #15's meal ticket on the lunch meal tray revealed no indication of Resident #15 having a cheese allergy. Interview at the time of observation on 04/10/24 at 12:50 P.M. with Resident #15 confirmed his allergy to cheese with Resident #15 stating I told them and my sister told them I am allergic to cheese, and I get cheese items all the time. Observation of Resident #15's meal tray and interview on 04/10/24 at 12:55 P.M. with Licensed Practical Nurse #361 confirmed Resident #15 had received au gratin potatoes. Review of the facilities Fall and Winter week one menu for 2023 and 2024 revealed golden brown chicken, au gratin potatoes, buttered lima beans, and iced lemon sugar was to be served for lunch on 04/10/24. Review of the facility concern report, dated 03/13/24, initiated by Resident #15 revealed he was allergic to cheese and was still receiving cheese. The facility follow up on the concern report indicated the tray card had been updated. (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 2 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 04/11/2024 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)