Health inspection·August 11, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on record review, staff interview, and review of the policy, the facility failed to conduct a timely post-fall investigation. This affected one (#76) of three residents reviewed for falls. The facility census was 89. Findings include: Review of the medical record for Resident #76 revealed an admission date of 11/23/22, with diagnoses including: chronic obstructive pulmonary disease (COPD), acute kidney failure (AKF), dementia without behavioral disturbance, and hypertension. Review of the fall risk assessment for Resident #76 dated 05/28/23 revealed resident was at risk for falls. Review of the Minimum Data Set (MDS) assessment for Resident #76 dated 07/01/23 revealed resident was cognitively impaired and required supervision and set up help with activities of daily living (ADLs.) Review of the nurse progress note for Resident #76 dated 07/25/23 revealed the resident had an unwitnessed fall and was found in his room lying on the floor perpendicular to his bed. Resident #76 reported he had fallen but couldn't state when the event had occurred. Resident #76 was sent to the hospital via 911 for an evaluation due to hip pain. Review of hospital notes for Resident #76 dated 07/25/23 revealed hip x-rays for resident were negative for fracture. Resident was found to have a urinary tract infection (UTI) and returned with orders for antibiotics. Review of the care plan for Resident #76 updated 08/07/23 revealed resident was at risk for falls. Interventions included the following: call light and personal items within reach when in room, anticipate needs and encourage resident to use call light, encourage resident to wait for assistance and not risk falls, ensure assistive devices readily available, ensure clutter free walkways, and minimize environmental hazards, maintain bed in lowest position with brakes on, communicate with members of the Interdisciplinary Team (IDT) to ensure continuity of care. Review of the facility post-fall investigation for Resident #76 dated 08/07/23 revealed the IDT met to discuss the resident's fall from 07/25/23. The facility was unable to determine root cause of the fall, but suspected UTI was a predisposing factor. The resident was treated for UTI and had no further falls since the fall on 07/25/23. Interview on 08/11/23 at 12:43 P.M., with the Director of Nursing (DON) confirmed the facility did (continued on next page) 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 (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366209 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods Edge Rehab and Nursing 1171 Towne Street Cincinnati, OH 45216 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)