Health inspection·November 5, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Review of the most recent care plan for Resident #59, revealed the resident resided on a secured unit to promote the resident's safety related to cognitive impairment, elopement risk, exit seeking behaviors, and wandering. Review of an unsigned /unlocked nurse's note dated 11/03/24 at 9:45 P.M. and authored by Licensed Practical Nurse (LPN) #500, revealed she was completing medication administration on A-Wing when she heard a noise coming from the 200-Hall door which leads to the second-floor secured unit. When LPN #500 opened the door, STNA #216 was in the stairwell asking if she had seen Resident #59 come down the stairs. STNA #216 stated Resident #59 was missing from the smoking room. The staff immediately searched inside and outside of the faciity and was unable to locate the resident. STNA #216 reported the police were outside the facility investigating a possible break in when they called the facility about the person they found walking around. The facility described the missing resident, and the police returned the resident within 15 minutes. The resident's assessment revealed no injuries and all vital signs within normal limits. The resident was returned to the secured unit and placed on 15-minutes checks by staff. All notifications were made to the responsible party and the physician, with no new orders. Review of the facility elopement investigation dated 11/03/24 completed by the Assistant Director of Nursing, (ADON) #304, revealed she was called by the staff on 11/03/24 around 10:00 P.M. indicating Resident #59 was missing from the facility. Resident #59 had been observed at 9:30 P.M. by State (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 3 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 11/05/2024 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)