St Mary Of The Woods
ST MARY OF THE WOODS in AVON, OH — inspection on August 28, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on medical record review, interviews, and review of facility policy, the facility failed to ensure the resident personal privacy and confidentiality of medical records was maintained.
This affected one resident (#63) of two residents reviewed for medical record release.
The facility census was 36.
Findings include: Interview with Resident #58's Family Member (FM) on 08/27/25 at 1:32 P.M. revealed she received Resident #58's medical records as requested from the facility, however; it also included another Resident's (#63) personal information, date of birth , insurance, diagnoses, and complete care plan.
Review of medical record package sent to Resident #58's FM by facility verified Resident #63's private information and medical information were included in the packet for Resident #58.
Interview with the Director of Nursing (DON) on 08/27/25 at 1:15 P.M. verified the medical record requested for Resident #58 also contained Resident #63's personal private and clinical information sent from the facility.
The DON also informed Resident #63's family of the breech in confidentiality and release of private information.
Review of facility policy titled, Release of Medical Records Policy. dated May 2022 revealed all medical records will be released with a valid request and in accordance with state and federal laws.
This deficiency represents non-compliance investigated under Complaint Number 2562366.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/28/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
St Mary of the Woods
35755 Detroit Road Avon, OH 44011
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review, staff interviews, and facility policy, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice and facility policy.
This affected one resident (#58) of three residents reviewed for oxygen administration.
The facility census was 36.Review of medical record for Resident #58 revealed an admission date of 04/01/25 with diagnoses of acute respiratory failure with hypoxia, Parkinson's disease, heart failure with ejection fraction of 42%, dysphagia, history of falls, hypertension, myocardial infarction, and cognitive deficits.
Review of the Minimum Data Set (MDS) assessment for Resident #58 dated 04/04/25 revealed the resident had cognitive decline as evidenced by a Brief Interview for Mental Status (BIMS) score of 11.
The resident was assessed to require some assistance for Activities of Daily Living (ADLs) but maximum assistance with hygiene/toileting needs related to shortness of breath with minimal exertion.
Resident also required continuous oxygen per nasal cannula at two to three liters per minute.
Record review of progress notes on 04/04/25 for Resident #58 revealed when the resident was having shortness of breath and restlessness with an oxygen saturation of 87-89%, the nurse placed a simple mask on the resident but left the oxygen flow rate at 3 liters per minute while awaiting the ambulance to transfer the resident to the hospital.Record review of the ambulance run report on 04/04/25 revealed when the squad arrived the resident's oxygen saturation at 89% with oxygen flow rate listed at only 1 liter per minute via simple mask.
Squad immediately increased the flow rate to 8 liters per minute and the resident became more responsive. Re-assessment of pulse oximetry revealed the oxygen saturation was up to 93%.
The resident was then transferred to the hospital and admitted with a diagnosis of respiratory failure.Interview on 08/26/25 at 8:19 A.M. with Licensed Practical Nurse (LPN) #406 stated she was aware of various oxygen flow rates for different oxygen delivery systems but could only state the parameters for nasal cannulas from one to five liters per minute. LPN #406 could not state what the flow rate would be for a simple mask or when she would place on a resident.Interview on 08/27/25 at 8:31 A.M. with LPN #387 was unable to state the flow rate parameters for the facilities oxygen delivery systems. LPN #387 stated he has never used a simple mask for a resident and only has used nasal cannulas.Interview of 08/27/25 at 2:06 P.M. with LPN #351 was unable to state the flow rate parameters for the facilities oxygen delivery systems. LPN #351 also had knowledge deficits related to the use of a simple mask.Observation of the facility's respiratory supply room revealed a large amount of respiratory equipment including nasal cannulas, high flow nasal cannulas, simple masks, aerosol treatment masks, and a non-rebreather mask.Interview with contracted Respiratory Therapist (RT) #516 on 08/27/25 at 3:40 P.M. revealed he was not onsite but supports the facility by setting up respiratory equipment for residents who need continuous positive airway pressure (CPAP), bilevel positive airway pressure (BIPAP) or tracheostomy oxygen set up with suctioning. He will also set-up water humidification for oxygen delivery systems that require humidification due to higher oxygen needs. RT #516 educates the staff on trach care and suctioning and performs the initial inner cannula exchange for trach residents. He stated he has not provided education to staff on oxygen flow rates.
Interview with the Director of Nursing (DON) on 08/27/25 at 3:55 P.M. verified RT #516 is available to assist staff but he is contracted from Respiratory Partners who supply the equipment and oxygen concentrators to the facility.
The DON stated she had not done education with staff regarding flow rates for the various oxygen delivery systems at the facility.Review of facility policy titled, Oxygen Administration, dated April 1, 2022 revealed a simple mask can deliver concentrations of 35-50% oxygen and requires a minimum of 5 liters/minute for use to prevent the resident from rebreathing carbon dioxide.This deficiency represents non-compliance investigated under Complaint Number 2562366.
Facility ID:
Federal health inspectors cited ST MARY OF THE WOODS in AVON, OH for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-28.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 3 deficiencies cited during this inspection of ST MARY OF THE WOODS.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-14.