F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Few
Findings include:
1. Review of Resident #342's medical record revealed an admission date of 03/02/24. A NOMNC letter
revealed services were ended on 03/22/24, the last covered day (LCD). Resident #342 discharged on
03/22/24, the LCD should have been 03/21/24. The NOMNC did not have the appeal agency phone number
listed and there was no resident name or identifying number on the notice.
2. Review of Resident #343's medical record revealed an admission date of 11/29/21. The resident started
skilled therapy on 02/20/24. A NOMNC letter revealed services were ended on 04/19/24, the LCD. Resident
#343 was discharged on 04/19/24, so the LCD should have been 04/18/24. Resident #343 signed the
notice on 04/19/24 and did not receive the required 48-hour notice, to be able to appeal the discharge date
. The NOMNC did not have the appeal agency phone number listed and there was no resident name or
identifying number on the notice.
3. Review of Resident #344's medical record revealed an admission date of 09/06/23. The resident started
skilled therapy on 01/25/24. A NOMNC letter revealed services were ended on 03/06/24. Resident #344
signed the notice on 03/06/24 and did not receive the required 48-hour notice, to be able to appeal the
discharge date . The NOMNC did not have the appeal agency phone number listed and there was no
resident name or identifying number on the notice.
Interview on 08/26/24 at 1:02 P.M. Social Service Coordinator #352 verified the NOMNC letters contained
the wrong dates for the last covered day, did not provide the residents the required time to appeal their
discharge date , did not provide the contact information for the appeal agency, and did not contain the
resident names or identifying information.
Interview on 08/28/24 at 12:05 P.M. with Administrator #355 revealed there was no policy for beneficiary
notices, the facility followed Medicare guidelines.
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 3
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
08/28/2024
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)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #65 revealed an initial date of admission of 10/15/22. Resident
#65 was readmitted to the facility after a recent hospital stay on 04/26/24. Significant diagnoses included
post-traumatic stress disorder, depression, presence of cerebrospinal fluid drainage device, anxiety, bipolar
disorder, and congenital hydrocephalus. Significant orders included Invega six milligrams (mg)
(antipsychotic) daily for psychosis, clonazepam 0.5 mg (benzodiazepine); give 0.25 mg by mouth every six
hours as needed for anxiety, regular, no salt packet diet, mechanical soft/dental soft texture, thin
consistency fluids and, Ensure (nutritional supplement) one can three times daily.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was
cognitively intact.
Review of the care plan dated 06/11/24 revealed Resident #65 was at risk for drug related side effects due
to the use of psychoactive drug regime. Interventions included monitor for change in appetite or weight. The
care plan also revealed on 12/08/23 Resident #65 had the behavior of binge eating and vomiting whole
food items. Interventions included to encourage Resident #65 to eat slowly and chew her food and sit
upright when eating.
Review of Resident #65's weights revealed on 02/04/2024, the resident weighed 242 pounds. On
08/23/2024, the resident weighed 211 pounds which is a 12.81 percent weight loss in six months.
Review of a dietary note dated 07/11/24 authored by Registered Dietitian/Licensed Dietitian (RD/LD) #367
revealed Resident #65 triggered for significant weight change. Meal intake varied averaging 50 percent.
RD/LD #367 made the recommendation for Resident #65 to obtain weekly weights.
Review of weight notes for Resident #65 revealed a weight of 211.2 pounds on 07/05/24 and a weight of
211.5 pounds on 08/23/24. There were no weekly weights noted in Resident #65 records.
On 08/28/24 at 11:35 A.M. an interview with RD/LD #367 revealed Resident #65 did not have the weekly
weights obtained as recommended on 07/11/24. RD/LD #367 stated she comes to the building weekly, and
there were no weights for review for Resident #65.
On 08/28/24 at 1:30 P.M. an interview with the Regional Director of Clinical Services (RDCS) #360 revealed
there were no weekly weights obtained for Resident #65. RDCS #360 verified the facility did receive the
recommendations from RD/LD #367 to obtain weekly weights for Resident #65 on 07/11/24.
Review of the facility policy titled; Weight Assessment and Intervention, dated September 2008, revealed
the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for
residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365658
If continuation sheet
Page 2 of 3
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
08/28/2024
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)
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Many
Findings include:
On 08/27/24 at 11:22 A.M. observation of the lunch tray line revealed all temperatures met or exceeded
requirements. The baked ham was 202 degrees Fahrenheit (F), the buttered noodles were 184 degrees F,
and the cabbage was 180 degrees F.
On 08/27/24 at 12:44 P.M. a test tray was assembled. The tray left the kitchen at 12:35 P.M., arrived at the
unit at 12:46 P.M. Nursing began passing the unit's lunch trays at 12:47 P.M.
On 08/27/24 at 12:57 P.M. all the lunch trays had been passed and the food temperatures of the test tray
were taken by Dietary Manager #354. The ham was 126 degrees F, the noodles were 108 degrees F, and
the cabbage was 111 degrees F. The food items all had good flavor; however, the temperatures were too
low for palatability. Dietary Manager #354 verified the tray temperatures at the time they were taken.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365658
If continuation sheet
Page 3 of 3
