Health inspection·December 3, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility Self-Reported Incidents (SRI), review of local law enforcement reports, interviews and facility policy review, the facility failed to protect Resident #71's right to be free from abuse by Resident #93 and failed to protect Resident #64's right to be free from abuse by Resident #88. This affected two residents (#71 and #64) of four residents reviewed for abuse. Actual Harm occurred on 11/13/25 when Resident #71 reported he had been inappropriately touched and choked by another Resident (#93). Upon assessment, Resident #71 was noted to have an abrasion to his lower neck and scratches to his left shoulder. Resident #71 complained of a sore throat and rectal tenderness. The resident's rectum was assessed to be reddened. The resident was transferred to the hospital for evaluation but subsequently declined having a rape assessment completed. Findings include:1. Review of the medical record for Resident #71 revealed an admission date of 09/02/25. Resident #71 had diagnoses including senile degeneration of the brain, unspecified dementia, and generalized muscle weakness.Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/08/25, revealed Resident #71 had impaired cognition and required supervision for bed mobility, transfers, and ambulation. Review of the behavior and mood section of the MDS revealed Resident #71 experienced hallucinations and wandering behaviors. Review of the plan of care dated 09/22/25 noted Resident #71 had impaired cognitive function/impaired thought process related to dementia. Resident #71 resided on the secured unit due to behaviors of elopement and lack of personal space regarding peers. Review of a nursing progress notes dated 11/13/25 at 3:20 A.M. noted Resident #71 reported inappropriate physical touch by another resident (Resident #93). The note included staff completed a thorough assessment noting Resident #71 had a slight abrasion on to the lower neck. Resident #71 also complained of a sore throat and rectal tenderness. A nursing progress note, entered in Resident #93's medical record dated 11/13/25 at 4:13 A.M. noted Resident #93 was observed by staff standing aggressively over Resident #71 and choking him.Review of a skin check evaluation dated 11/13/25 at 5:17 A.M. noted Resident #71 had a reddened rectum and scratches on the front of his left shoulder.Review of a nurse's progress note dated 11/13/25 at 9:20 A.M. noted Resident #71 reported his rectum was burning like fire. Resident #71 was transferred to the hospital for an evaluation. A nursing progress note dated 11/13/25 at 9:33 P.M. noted Resident #71 declined all rape assessments while at the hospital and would be returning to the facility. Review of the local hospital record dated 11/13/25 noted Resident #71 received a computerized tomography (CT) scan to brain, cervical (neck), face, chest, and right elbow. The hospital record noted Resident #71 declined rape assessments. Review of a facility SRI tracking number 267485 dated 11/13/25 noted Certified Nurse Assistant (CNA) #353 heard Resident #71 yell out and immediately went into the resident's room. CNA #353 stated she observed Resident #93 leaning over Resident #71. Resident#71 stated he was woken up when Resident #93 placed his right leg on his chest and started choking him. Resident #71 stated Resident #93 inserted his finger Page 1 of 3 365658 365658 12/03/2025 Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057

F 0600 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. into his rectum. Both residents were placed on 1:1 observation for safety. The facility contacted all responsible parties including the local law enforcement agency. However, review of the SRI revealed the facility unsubstantiated an incident of physical abuse citing there was not enough evidence. Review of a local law enforcement report dated 11/13/25 at 4:52 A.M. noted a report of an assault was called in from the facility. Interview with law enforcement and Resident #71 noted Resident #71 was lying down in bed when his roommate Resident #93 tried to touch him. Resident #71 said he asked Resident #93 to go to bed. Resident #71 stated Resident #93 had his hand where it should not be, and he asked Resident #93 to stop. Resident #71 stated he again asked Resident #93 to stop and go to bed. Resident #71 stated Resident #93 kept standing over and touching him. Resident #71 stated Resident #93 got him down on the bed and started choking him. Resident #71 stated he had a difficult time breathing at that point. Resident #71 continued to say Resident #93 started using his finger on his butt when he was lying on his side for approximately 15 minutes. The law enforcement agency interviewed Resident #93 who had no memory of the incident. Interview with Resident #71 on 11/25/25 at 2:05 P.M. revealed Resident #93 wanted more than he was willing to give. Resident #71 stated Resident #93 wanted to have sex and was standing over him slapping him in the face and choking him. Resident #71 then stated Resident #93 pulled his pajamas down to stick his finger in his rectum. Resident #71 stated staff came in and separated them and then removed Resident #93 the following day. (Resident #71 and Resident #93 were roommates at the time of the incident). Attempts to interview CNA #353 during the onsite investigation were unsuccessful. Interview on 11/25/25 at 9:59 A.M., with the Administrator revealed the facility was unaware of any behaviors by Resident #93 until this incident on 11/13/25. Following the incident, the facility contacted Resident #93's parole officer and the resident was going back to prison. (Resident #93 had been incarcerated beginning in 1982 for aggravated murder, aggravated robbery, and felonious assault and was released from prison directly to the facility for admission on [DATE]).Interview on 12/03/25 at 12:48 P.M. with the Administrator revealed Resident #93's parole officer indicated the incident involving Resident #93 on 11/13/25 was a parole violation, therefore Resident #93 would be sent back to prison. Resident #93 was sent to the hospital after the incident on 11/13/25 and did not return to the facility.2. Review of the medical record for Resident #64 revealed an admission date of 05/28/21. Resident #64 had diagnoses including anxiety disorder, Alzheimer's disease, and unspecified dementia. Review of the plan of care dated 01/21/25 noted Resident #64 had behaviors of masturbation in an open setting.Review of the quarterly MDS assessment dated [DATE], revealed Resident #64 had intact cognition. The resident was independent with activities of daily living. Review of facility SRI tracking number 267239 dated 11/06/25 noted Licensed Practical Nurse (LPN) #368 reported Resident #88 was observed in Resident #64's room engaging in sexual activity. The SRI included both residents were separated immediately and placed on 15-minute checks for 72 hours. Interview on 11/24/25 at 4:04 P.M., with the Regional Director of Clinical Services # 391 and the Director of Nursing (DON) revealed Resident #88 had attempted to have sex with many male peers on the unit, but staff had (previously) been able to prevent that until 11/06/25. Both staff stated the facility purchased Resident #88 a pleasure device which was kept locked up. Staff also stated they changed Resident #88's medications to decrease her sexual behaviors. Interview on 11/25/25 at 11:06 A.M. with Resident #64 revealed (on 11/06/25) Resident #88 entered his room and closed the door. Resident #64 stated he told Resident #88 to leave his room, but she refused to leave stating she liked him and wanted to have sex. Resident #64 stated Resident #88 pulled his pants and underwear down before touching him. Resident #64 stated he did not like Resident #88 and did not want to have sex with her. Review of the facility policy titled Abuse and Neglect-Clinical Protocol, dated 365658 Page 2 of 3 365658 12/03/2025 Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057

F 0600 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. 2018, noted staff would assess all residents involved in allegations of abuse and/or neglect. The nurse would report all related findings to the physician. The staff, with the help of the physician's input, would investigate alleged abuse and neglect to clarify what happened and identify possible causes. The staff and the physician would monitor individuals who have been abused to address any issues regarding their medical condition, mood, and function. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. The policy defined sexual abuse as non-consensual sexual contact of any type with a resident. This deficiency represents noncompliance investigated under Master Incident Number 2676134, Complaint Number 2675465 and Incident Number 2671068. 365658 Page 3 of 3