Cardinal Woods Skilled Nursing & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Cardinal Woods Skilled Nursing & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 14, 2023

  Based on observation, record review, review of a facility investigation, review of a Materials Safety Data sheet and interviews with facility staff and Resident #10's daughter, the facility failed to ensure the environment on the memory care unit was free of accident hazards and failed to provide adequate supervision to prevent Resident #10, who was severely cognitively impaired and exhibited wandering behavior from obtaining and ingesting liquid from an unsecured bottle of all-purpose lemon scented cleaner with bleach. This resulted in Immediate Jeopardy on 12/22/22 at 12:30 A.M. when State tested Nursing Assistant (STNA) #214 placed a bottle of cleaner with bleach on the microwave oven in the dining room of the memory care unit. […]

• Actual harm, isolatedF600Jul 16, 2026

  Based on record review, facility self-reported incident (SRI) review and investigation, interviews and facility policy review, the facility failed to protect Resident #96's right to be free from physical abuse by another resident. Actual harm occurred on 06/23/26 when Resident #96 sustained a fall after being struck by Resident #87 resulting in rib fractures requiring hospitalization and treatment for a pneumothorax (collapsed lung). Resident #96 remained hospitalized through 07/01/26 and then was discharged to a different facility at the request of his family. This affected one (Resident #96) of three residents reviewed for abuse. The facility census was 95. […]

• Actual harm, isolatedF692May 28, 2026

  Based on medical record review, observations, interviews, and policy review, the facility failed to implement a comprehensive, individualized, and effective nutrition program to prevent and address significant resident weight loss. Actual harm occurred on 03/20/26 when the facility identified Resident #75 experienced an unplanned significant weight loss of 22.6 percent (%) in approximately one month, and failed to implement appropriate interventions, provide continued monitoring of the resident's weight, or notify the physician of concerns. Subsequently, Resident #75 experienced a second unplanned weight loss of 6.82% approximately two months later. In total, Resident #75 experienced a significant weight loss of 27.8% in approximately three months. […]

• Actual harm, isolatedF600Dec 3, 2025

  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. […]

• Actual harm, isolatedF600Apr 10, 2025

  Based on record review, review of the facility self-reported incident (SRI) and investigation, review of facility policy, observation and interview, the facility failed to ensure Resident #12 was free from physical abuse by Resident #40. Actual harm occurred on 03/16/25 when Resident #40, who had known verbal and physical aggressive behaviors towards others, punched Resident #12 in the face, head, and neck approximately 20 times resulting in facial and scalp contusions, headache and neck pain requiring evaluation and treatment in the hospital emergency room (ER). Resident #12 had X-rays, and a Computed Axial Tomography (CAT) scan performed while in the ER which indicated there were no broken bones. Resident #12 was diagnosed with physical assault, head, face, and neck contusions. […]