Woods Edge Rehab: Infection Control Failures - OH
The man at the center of that lapse, identified in inspection records only as Resident 15, had been placed on Enhanced Barrier Precautions, an infection control designation used specifically to stop the spread of multidrug-resistant organisms. He had a stage IV pressure ulcer on his left heel, the most severe classification, a wound so deep it can expose muscle, tendon, or bone. He also had Alzheimer's dementia, hemiparesis, and peripheral vascular disease, and required a legal guardian to make decisions on his behalf. He could not advocate for himself during the procedure.
Federal inspectors observed the wound care on November 25 at 1:21 in the afternoon. Two licensed practical nurses and a certified nursing assistant were present. Before putting on gowns and gloves, all three washed and dried their hands. That was the last time hand hygiene was performed correctly.
LPN 174 cut the old dressing with scissors, peeled it away, and dropped it in the trash. Then she washed her hands but put on new gloves without performing any hand hygiene first — a sequence that reverses the purpose of washing. She cleansed the wound with gauze, discarding each piece as she went, then removed the soiled gloves and applied fresh ones, again without washing her hands between.
Then she left the room.
LPN 174 walked out still wearing the isolation gown and gloves she had used during wound care on a patient under enhanced precautions. She had forgotten the wound cleanser. She retrieved it and came back in, still in the same gown, still in the same gloves, and continued the procedure. She applied Santyl to gauze, packed the wound, wrapped it in Kerlix, and taped the dressing. Then she left again, PPE still on.
She came back a third time, black marker in hand, to initial and date the dressing. Still wearing the same gown. Still wearing the same gloves.
When inspectors spoke with her at 1:47 that afternoon, LPN 174 confirmed she understood what she had done wrong. She verified she should have removed the gown and gloves before leaving the room the first time. She verified she should have washed her hands after removing the soiled gloves during wound cleansing, and again before applying the fresh pair.
The director of nursing, interviewed the same morning before inspectors had observed the wound care, described the standard clearly. Staff were expected to gather all supplies before beginning any care. Proper infection control techniques were required during wound care. A week later, on December 1, the director of nursing elaborated: removing a gown before exiting a resident's room, washing hands before starting wound care, washing hands any time gloves come off, washing hands after touching anything soiled, washing hands before applying a clean dressing, washing hands after completing the treatment. The director confirmed all of that was standard nursing practice and that staff were expected to follow it.
The facility's own written policy for aseptic dressing changes, dated January 2024, lists those steps in sequence. Its Enhanced Barrier Precautions policy, updated March 2024, specifies that precautions apply to residents with wounds regardless of whether a multidrug-resistant organism has been confirmed, and that proper application and removal of gown and gloves are required during high-contact care activities. Wound care is explicitly listed.
None of that happened.
The inspection was a complaint investigation. Inspectors reviewed wound care practices for three residents and found the breakdown in one. The facility's census at the time was 75.
Resident 15 could not tell anyone what was happening during his wound care. He could not ask why the nurse was leaving the room in her isolation gown, or why she came back without changing it, or whether the hands touching his open wound had been washed. His guardian was not present. The staff who were present said nothing.
The stage IV wound on his left heel remained open when inspectors left the building.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woods Edge Rehab and Nursing from 2025-09-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 11, 2026 · Our methodology
WOODS EDGE REHAB AND NURSING in CINCINNATI, OH was cited for violations during a health inspection on September 30, 2025.
He had a stage IV pressure ulcer on his left heel, the most severe classification, a wound so deep it can expose muscle, tendon, or bone.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.