Inspection·June 28, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based 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. Findings include: Review of the medical record for Resident #58 revealed an admission date of 01/04/18 with diagnoses including fracture of the left femur on 01/28/20, chronic pain syndrome, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/09/24, revealed Resident #58 had intact cognition. The assessment revealed the resident required substantial/maximal assistance for showers, upper body dressing, and lower body dressing. The assessment also noted the resident used a power wheelchair for mobility. Review of the plan of care (initiated 01/18/18) and last revised on 05/12/24 revealed the resident was at risk for falls due to a history of falls, poor safety awareness, and non-compliance with fall interventions. On 02/09/22 the care plan interventions were updated to include staff education to never leave the resident unattended during shower. Review of a nursing note dated 06/08/24 at 2:12 P.M. revealed Resident #58 had a fall in the shower. Agency Licensed Practical Nurse (LPN) #306 and Agency State Tested Nursing Assistant (STNA) #305 were sitting at the nursing station and heard the resident call out for help. Agency STNA #305 went to check on the resident and came back to the nursing station and stated the resident was on the floor. When the nurse got into the shower room the resident was lying on her left side. The resident stated she was trying to fold a blanket that was on the floor and fell onto her right side. The resident stated she couldn't move her leg and that her hip was hurting her badly, rating her pain a ten, on a scale from zero to ten, ten being severe. The nurse gave the resident as needed (PRN) pain medication and called 911 for transport. Resident #58 was taken out via stretcher to the hospital. Review of the nursing note dated 06/08/24 at 6:23 P.M. revealed the nurse spoke with the hospital. Resident #58 had a right hip fracture. Review of the fall investigation dated 06/08/24 revealed the investigation reflected the contents (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 06/28/2024 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)