Woods Edge Rehab and Nursing

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policy, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 75 of 77 residents who received food from the kitchen. Two residents received no food by mouth. The facility census was 77 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to properly label and store medications. This affected seven residents (Resident #20, Resident #55, Resident #36, Resident #37, Resident #58, Resident #75, and Resident #7) of 18 residents reviewed for medication storage. The facility census was 77 residents.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to ensure call lights were within reach. This affected one (Resident #47) of 18 residents reviewed for call lights. The facility census was 77 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure a clean and sanitary environment. This affected one (Resident #38) of 18 residents sampled. The facility census was 77 residents.

Inspectors wroteBased on medical record review, review of the facility fall investigation, staff interview, and review of the facility policy, the facility failed to provide adequate the adequate level of supervision and assistance during care to prevent falls. This affected one (Resident #84) of three residents reviewed for falls. The facility census was 77 residents.

Inspectors wroteBased on observation, staff interview and review of the facility policy, the facility failed to ensure nurses performed appropriate hand hygiene during medication administration. This affected three residents (Resident #11, Resident #76 and Resident # 38) of five residents observed for medication administration. The facility census was 77 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure that residents were offered the pneumococcal vaccine upon admission and annually. This affected three residents (Resident #22, #38, and Resident #2) of five residents reviewed for vaccines. The facility census was 77 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to offer Coronavirus (COVID-19) vaccines to residents upon admission and annually. This affected two residents (Resident #2 and Resident #38) of five residents reviewed for vaccines. The facility census was 77 residents.

Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to ensure a resident's falls were thoroughly investigated, properly documented in the medical record, a fall risk assessment was completed, a post-fall evaluation completed and assure immediate fall interventions were implemented. This affected one (Resident #39) of the three residents review for falls. The facility also failed to ensure residents were assessed following a fall. This affected one (Resident #49) out of three residents reviewed for falls. The facility census was 75.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control techniques were properly maintained during wound care. This affected one (Resident #15) of three Residents reviewed for wound care. The facility census was 77.

Inspectors wroteBased on medical record review, observation, staff interview, review of the facility's investigation, review of witness statements, review of the facility Self-Reported Incidents (SRI), review of emergency medical services (EMS) report, review of hospital records, review of emergency room (ER) notes, review of the local weather report, and review of the facility policy, the facility failed to provide adequate supervision and implement timely interventions for exit-seeking behaviors for Resident #11, to prevent his elopement from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or death on [DATE] when Resident #11 broke the window and exited the secured building by jumping out of the second story window, approximately 15 feet from the ground level. Resident #11 suffered an open fracture to the left ankle as a result of the jump. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control techniques were properly maintained during wound care. This affected one (Resident #15) of three Residents reviewed for wound care. The facility census was 75.

Inspectors wroteBased on medical record review, review medication administration records and controlled drug records, staff interview, and policy review, the facility failed to ensure administration of a narcotic pain medication was documented on the medication administration record. This affected one (#13) of three residents reviewed for medication administration documentation. The facility census was 83.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to properly label prepared foods in the refrigerator. This had the potential to affect all residents residing in the facility who receive food from the kitchen. The facility census was 85.

Inspectors wroteBased on interview, observations and record review, the facility failed to serve specialized diets as planned by the Registered Dietitian (RD). This affected 15 residents, (#01, #15, #20, #21, #22, #32, #41, #52, #61, #66, #67, #69, #72, #77, and #87) of the 89 residents receiving food from the kitchen. The facility census was 90. Findings Include: Review of the physician orders revealed Residents #01 and #69 had diet orders for puree food texture consistency. Residents #15, #20, #21, #22, #32, #41, #52, #61, #66, #67, #72, #77, and #87 had physician orders for a mechanical soft food texture consistency. Review of the lunch menu diet spreadsheet revealed the puree texture diet was to be served puree green beans. The mechanical foods texture diets were to be served green beans. Observation on 11/04/24 at 11:40 A.M. [...]

Inspectors wroteBased on staff interviews, observations and record review, the facility failed to provide adequate supervision to prevent the elopement of one (#59) of the three residents reviewed. The facility census was 90. Findings Include: Review of the medical record for Resident #59 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia, dementia, chronic obstructive pulmonary disease (COPD), diabetes, drug abuse, and tobacco use. Review of a physician order dated 01/24/24 for Resident #59, revealed the resident was ordered to be on a secured unit due to vascular dementia and schizophrenia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #59 had moderately impaired cognition and was independent for ambulation. The resident resided on a secured behavior unit. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure menus were followed and residents were notified of menu changes prior to the meal. This had the potential to affect 88 of 89 residents. The facility identified one Resident (Resident #33) who did not receive food from the kitchen. The facility census was 89.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure recipes were followed and that the food was visually appealing. This had the potential to affect 88 of 89 residents. The facility identified one resident (Resident #33) who did not receive meals from the kitchen. The facility census was 89.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure employees wore hair nets while preparing and serving food and beverages. This had the potential to affect 88 of 89 residents. The facility identified one resident (Resident #33) who did not receive food from the kitchen. The facility census was 89.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure residents were fed in a safe and dignified manner. This affected one (Resident #64) of one resident reviewed for dignity. This had the potential to affect all 89 residents in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a resident's compression stockings were applied as ordered to treat edema. This affected one (Resident #80) of three residents reviewed for edema. The facility census was 89.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure residents were seen by the physician as required. This affected one (Resident #80) of three residents reviewed for physician visits. The facility census was 89.

Inspectors wroteBased on observations, staff interviews, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This had the potential to affect all but one resident (#17) who facility identified as not receiving food from the kitchen. The facility census was 86.

Inspectors wroteBased on record review, observations, staff interviews, and review of facility policy, the facility failed to provide a clean, sanitary, and homelike environment. This affected one (#15) resident of the three residents reviewed for environment. The facility census was 86.

Inspectors wroteBased on review of personnel records and staffing schedules, staff interview, and review of the State of Ohio Nurse Aide Registry, the facility failed to ensure a state tested nursing assistant's (STNA) registration was not expired. This affected one (STNA #10) of three personnel files reviewed. This had the potential to affect sixteen residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) that STNA #10 regularly cared for. The facility census was 86.

Inspectors wroteBased on the staffing punch detail, review of the schedule, and staff interview, the facility failed to ensure there was Registered Nurse (RN) coverage for eight consecutive hours, seven days each week. This had the potential to affect all residents. The facility census was 79.

Inspectors wroteBased on observation, review of the dishwasher manufacturer's recommendations, review of facility policy, and staff interview, the facility failed to ensure the kitchen was maintained in a sanitary manner, dishware was properly sanitized, and food was stored to prevent contamination. This affected 77 residents who received food from the kitchen. Resident #5 and #54 received no food by mouth. The facility census was 79.

Inspectors wroteBased on observation, review of orders for dietary products, and staff interview, the facility failed to ensure residents were not served on disposal plates. This affected 24 (#2, #6, #12, #13, #15, #16, #21, #23, #26, #28, #34, #39, #40, #41, #49, #50, #51, #60, #61, #64, #67, #68, #69 and #75) residents out of 77 residents that received meals from the facility kitchen. The facility census was 79.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were provided Notice of Medicare Non Coverage (NOMNC) to inform the resident of the right to an expedited review of a services termination or Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) to inform the resident of the potential liability for a non covered stay. This affected three (#24, #233, and #234) out of three residents reviewed for beneficiary notices. The facility census was 79.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide daily activities of daily living (ADL) in the form of hair care, hygiene, dressing, and getting out of bed for one (#27) out of 23 residents reviewed. The facility census was 79.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure residents were provided activities. This affected two (#27 and #46) out of three residents reviewed for activities. The facility census was 79.

Inspectors wroteBased on observations, medical record, resident and staff interviews, the facility failed to ensure a resident was served a meal to accommodate her food preference. This affected one (#14) of one resident reviewed for meal preferences and allergies. The facility census was 79.

Inspectors wrote2. Resident #15 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, acute kidney failure, heart failure, major depressive disorder, hyperlipidemia, type two diabetes mellitus, hypertension, aphasia, and seizure disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of seven out of 15, required extensive physical assistance of two or more persons for bed mobility, transfers, and toilet use. Review of the Morse Fall Scale for fall risk dated 02/21/19 revealed Resident #15 was at high risk for falls with a score of 60, indicated by a score of 45 or higher. Review of the comprehensive care plan revealed no evidence of a fall risk care plan. Review of the Incident Note dated 05/26/19 at 6:43 P.M. [...]

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to have call lights in easy reach for resident. This affected one (#80) out of 88 residents observed. The facility census was 88.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to provide residents access to their money on weekends. This affected three (#14, #41 and #50) out of nine residents reviewed for personal funds. The facility managed funds for 79 residents. The census was 88.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident's Do Not Resuscitate (DNR) code statuses were documented on a valid form. This affected one (#6) out of 24 residents reviewed during the initial pool screening of the annual survey. The facility census was 88.

Inspectors wroteBased on medical record review and resident and staff interviews, the facility failed to notify the ombudsman and the resident of the transfer regarding the reasons for the discharges from the facility in writing. This affected three (#29, #41 and #78) out of five residents reviewed for discharge notification. The facility census was 88.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident's discharge status was accurately coded on the Minimum Data Sets (MDS) assessment. This affected one (#89) of 21 residents reviewed for accuracy of assessments. The facility census was 88.

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop accurate baseline care plans for residents within 48 hours of their admission. This affected three (#41, #57 and #84) of 21 residents reviewed for baseline care plans. The facility census was 88.

Inspectors wroteBased on medical record review and resident and staff interview, the facility failed to ensure a resident's fall risk care plan was reviewed and revised. The facility also failed to ensure residents were allowed the opportunity to participate in care planning. This affected three (#6, #13 and #15) out of 21 residents reviewed for care planning. The facility census was 88.

Inspectors wroteBased on medical record review, observation and resident and staff interview, the facility failed to ensure fall risk interventions were implemented to prevent falls. The facility also failed to transfer a resident based on assessed transfer needs which resulted in a resident having an avoidable fall. This affected two (#13 and #15) of five residents reviewed for falls. The facility census was 88.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure psychotropic medication ordered on an as needed (PRN) basis was not prescribed for an indefinite period of time. This affected one (#44) of five residents reviewed for unnecessary medications. The facility census was 88.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure documentation of a resident's hospice provider was accurate in the medical record. This affected one (#2) of 21 residents reviewed for complete and accurate medical records. The facility census was 88.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to ensure a resident was provided with a safe and functional room. This affected one (#27) out of 24 residents reviewed. The facility census was 88.