Cardinal Woods Skilled Nursing & Rehab Ctr
For profit - Corporation · 6831 Chapel Road, Madison, OH 44057 · See home’s Medicare page
Special Focus Facility Candidate
Has a history of serious quality issues but has not been formally flagged by the government.
Inspections Delayed
The most recent standard inspection occurred more than two years ago. Inspections are supposed to occur every 9 to 15 months.
Affiliated With Aom Healthcare
People or companies with an ownership interest in or managerial control of this home, according to CMS data.
2.98
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.6
55.0%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 51.6%
120
Certified beds
Qualifying beds in the certified provider or supplier facility.
97
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
Pointe Woods Investment Llc (100%)
Indirect owners
Jeffrey Goldstein (33%)
Alexander Sherman (33%)
Samuel Sherman (33%)
Alexander Sherman (33%)
Samuel Sherman (33%)
Managerial control
Alexander Sherman since Apr, 2017
Samuel Sherman since Jul, 2017
Samuel Sherman since Jul, 2017
Managing employee(s)
No information available
Inspection Reports
54
total deficiencies
4
infection-related deficiencies
This home violated federal standards protecting residents from the spread of infections.
Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
Apr 11, 2024
1 deficiency
Nutrition and Dietary Deficiency — F0806
Failure to:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Feb 7, 2024
1 deficiency
Resident Rights Deficiency — F0584
Failure to:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Dec 5, 2023
1 deficiency
Quality of Life and Care Deficiency — F0689
Failure to:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Feb 14, 2023
3 deficiencies
to
K
Jun 27, 2022
18 deficiencies
to
F
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Infection Control Deficiency — F0881
Failure to:
Implement a program that monitors antibiotic use.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Resident Rights Deficiency — F0565
Failure to:
Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Nutrition and Dietary Deficiency — F0803
Failure to:
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Nutrition and Dietary Deficiency — F0804
Failure to:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Nutrition and Dietary Deficiency — F0812
Failure to:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Administration Deficiency — F0835
Failure to:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Environmental Deficiency — F0921
Failure to:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Quality of Life and Care Deficiency — F0692
Failure to:
Provide enough food/fluids to maintain a resident's health.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0580
Failure to:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Nutrition and Dietary Deficiency — F0805
Failure to:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0582
Failure to:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0656
Failure to:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0695
Failure to:
Provide safe and appropriate respiratory care for a resident when needed.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0550
Failure to:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Feb 16, 2022
4 deficiencies
to
F
Nutrition and Dietary Deficiency — F0802
Failure to:
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Nutrition and Dietary Deficiency — F0804
Failure to:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Nutrition and Dietary Deficiency — F0805
Failure to:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0806
Failure to:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Dec 13, 2021
3 deficiencies
to
G
Pharmacy Service Deficiency — F0760
Failure to:
Ensure that residents are free from significant medication errors.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0804
Failure to:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Nutrition and Dietary Deficiency — F0806
Failure to:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Sep 23, 2021
1 deficiency
Nutrition and Dietary Deficiency — F0804
Failure to:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Aug 30, 2021
2 deficiencies
to
F
Nutrition and Dietary Deficiency — F0812
Failure to:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Nutrition and Dietary Deficiency — F0809
Failure to:
Ensure meals and snacks are served at times in accordance with resident's needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Jul 8, 2021
3 deficiencies
to
F
Nutrition and Dietary Deficiency — F0804
Failure to:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0842
Failure to:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
May 16, 2019
9 deficiencies
to
F
Nutrition and Dietary Deficiency — F0812
Failure to:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Environmental Deficiency — F0926
Failure to:
Have policies on smoking.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0584
Failure to:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
Failure to:
Respond appropriately to all alleged violations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0656
Failure to:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0689
Failure to:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Apr 5, 2018
8 deficiencies
to
F
Nutrition and Dietary Deficiency — F0812
Failure to:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Pharmacy Service Deficiency — F0761
Failure to:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Quality of Life and Care Deficiency — F0677
Failure to:
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0686
Failure to:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0693
Failure to:
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0807
Failure to:
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Penalties
$155K
total fines
1
payment suspension
A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.