Health inspection·April 10, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, osteoporosis, uterine cancer, and chronic pain. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #13 had severe cognitive impairment and was frequently incontinent of bowel and bladder. The resident required supervision with eating and was dependent for oral and personal hygiene, toileting, bathing, dressing, bed mobility, and transfers. Review of the census profile revealed Resident #13 transitioned to hospice services on 08/14/24. Review of physician orders revealed Resident #13 had an order dated from 08/14/24 to 02/27/25 for the administration of the narcotic pain medication morphine sulfate solution 20 milligrams per milliliter (mg/ml) with instructions to give five (5) mg by mouth every four hours as needed for pain/dyspnea (0.25 ml). The order was renewed on 02/27/25. Review of the September 2024 medication administration record (MAR) revealed Resident #13 received one documented dose of morphine administered on 09/27/24 at 10:41 A.M. by Licensed Practical Nurse (LPN) #405. Review of the controlled drug record for Resident #13's physician ordered morphine sulfate solution revealed doses were signed out on 09/15/24 at 9:00 P.M., on 09/27/24 at 12:00 P.M. and 5:00 P.M., on 09/28/24 at 7:20 P.M., and on 09/29/24 at 7:58 P.M. Review of the October 2024 MAR revealed Resident #13 received two documented doses of morphine on 10/03/24 at 5:55 P.M. by LPN #410 and 10/08/24 at 12:35 P.M. by LPN #410. Review of the controlled drug record for Resident #13's physician ordered morphine sulfate solution revealed doses were signed out on 10/01/24 at 6:00 P.M., on 10/03/24 at 6:00 P.M.,on 10/04/24 at 7:20 P.M., on 10/07/24 at 9:00 A.M. and 9:30 P.M., on 10/08/24 at 12:00 P.M., and on 10/09/24 at 9:15 (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 04/10/2025 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)