Woods Edge Rehab And Nursing
WOODS EDGE REHAB AND NURSING in CINCINNATI, OH — inspection on September 30, 2025.
Found 2 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
During an interview on [DATE] at 2:00 P.M., the Administrator stated she had not started employment with the facility until after the incident with Resident #11 occurred.
The Administrator stated the original investigation which was conducted by the acting Administrator on [DATE] could have been tighter.
The Administrator felt LPN #205 changed his story as the surveyor's investigation progressed and the administration asked follow-up questions. LPN #205 left the country on a planned leave of absence within a few days after [DATE] and was not available for questioning again until [DATE].
The Administrator confirmed the incident involving Resident #11 occurred due to to lack of adequate supervision of Resident #11 on [DATE].
The Administrator confirmed the facility did not have a policy regarding supervision of residents threatening to harm themselves or others.
However, the facility did have training documents regarding resident safety and supervision during a behavioral emergency.
The Administrator confirmed staff were trained upon hire to not leave residents unattended if they threaten to hurt themselves or others and the onboarding training document was used in staff re-education following the incident on [DATE].
Review of the facility SRI regarding the incident with Resident #11 dated [DATE] at 4:44 P.M. revealed the facility initiated an investigation of an allegation of abuse/neglect when the Resident #11 threatened to staff that he was going to break a window and jump out.
The brief description of the incident indicated Resident #11 who resides in a secured male unit, who has a history of an anoxic brain injury, schizoaffective disorder, has impulsivity, and poor decision-making impairments threw himself through a plated glass window causing a fall onto the ground.
The facility concluded the investigation on [DATE] at 2:09 P.M., but did not substantiate neglect, due to the resident's behaviors and impulsivity.
Review of the weather report for [DATE] at 2:00 P.M. revealed a temperature of 79 degrees Fahrenheit (F), mostly clear, with no precipitation.
Review of the facility policy titled Elopement Prevention and Management Unsafe Wandering and Exit Seeking Behavior dated [DATE] revealed the facility strives to prevent resident elopement and would develop a care plan and implement individualized interventions to prevent elopement.
Review of the facility training document undated and untitled used for onboarding new hires and used again in the facility safety re-education initiated on [DATE] revealed a resident threatening to hurt themselves or others was a mental health crisis requiring immediate intervention.
Immediate actions included the following: do not leave the resident alone, maintain continuous observation of the resident, do not leave the resident unsupervised, call for backup immediately, use a code word (Code 4-behavioral emergency) to discreetly alert staff, supervisor, and security.
Further review of the document revealed even if staff felt the resident would not commit to hurting themselves or someone else, the threat should be reported immediately to the Administrator and the DON, and the resident should be placed on one-on-one supervision.
This deficiency represents noncompliance at investigated under Complaint Number 2614502.
366209 09/30/2025
Woods Edge Rehab and Nursing 1171 Towne Street Cincinnati, OH 45216
Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 was cognitively impaired and dependent on staff for activities of daily living (ADL).
Was assessed to have a stage IV pressure ulcer (a severe, full-thickness wound with extensive tissue loss, exposing muscle, tendon, ligament, or bone) on his left heel. An observation of wound care and dressing change to the left heel of Resident #15 on 11/25/25 at 1:21 P.M. with Licensed Practical Nurse (LPN) #106, LPN#174, and Certified Nursing Assistant (CNA) #120. Resident #15 was noted to be in EBP.
Prior to putting on gowns and gloves, all staff washed and dried hands.
While LPN #106 was holding Resident #15 ' s left leg up off the bed, LPN #174 used scissors to cut the old dressing, removed the soiled dressing and placed it in the trash with soiled gloves. LPN #174 washed hands and applied new gloves with no hand hygiene. LPN #106 asked where the wound cleanser was, then LPN #174 exited the resident ' s room with her isolation gown in place and returned with wound cleaner. LPN #174 applied gloves, cleansed the wound with gauze and cleaner, disposed of each gauze used to clean, removed soiled gloves and applied fresh gloves without any hand hygiene between. LPN #174 applied Santyl to gauze, applied gauze to left heel, wrapped the dressing in Kerlix, applied tape to dressing and exited room with her personal protective equipment (PPE) still in place. LPN #174 returned to room still in same gown and gloves, with a black marker, and initialed and dated the dressing.
Interview on 11/25/25 at 1:47 P.M., LPN #174 verified she should have removed the gown and gloves prior to exiting resident ' s room. LPN #174 verified she should have completed hand hygiene after removing the soiled gloves following the wound cleansing and prior to applying new gloves when she applied the wound treatment.
Interview on 11/25/25 at 9:21 A.M., DON stated the staff were expected to bring in all supplies prior to beginning any type of care the staff should be following the proper infection control techniques when doing wound care.
Subsequent interview on 12/01/25 at 9:47 A.M., the DON stated the facility policy on EBP included the proper use of gloves and gown and the facility policy on Aseptic Dressing Change included the proper hand hygiene.
The DON verified it was standard nursing practice to remove a gown prior to exiting a resident ' s room and applying a clean gown prior to re-entry, washing hands before you start wound care, anytime take your gloves off, touch anything soiled, going to clean dressing wash hands, and after you have completed the treatment.
The DON stated the staff were expected to follow policies and procedures for infection control.
Review of facility policy for Aseptic Dressing Change dated January 2024, revealed steps that include placing soiled dressing in trash, washing hands, applying clean gloves to cleanse wound, discarding cleansing supplies to trash, wash hands and apply gloves, apply medication and clean dressing, remove gloves and place in trash, tape dressing ion place, date and initial according to facility policy.
Review of facility policy on EBP dated March 22, 2024, revealed EBP for residents with wounds regardless of MDRO colonization status should be ordered and followed by staff during high-contact resident care activities including wound care.
These precautions include the proper application and removal of gloves and gown.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.