Health inspection·August 28, 2024

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. Page 1 of 3 365658 365658 08/28/2024 Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057

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. 365658 Page 2 of 3 365658 08/28/2024 Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057

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. 365658 Page 3 of 3