Health inspection·December 1, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 11/24/25 at 4:03 P.M., LPN #176 stated she was the nurse responsible for Resident #49 on 11/21/25 when Resident #49 was found on the floor around 2:30 A.M. LPN #176 stated Resident #49 was found on the floor with blood coming from her nose and a hematoma over her left eye. LPN #176 stated she called 911 for Resident #49 to be sent to the emergency room. LPN #176 stated when Emergency medical Services (EMS) arrived, they felt Resident #49 was stable and did not need to be taken to the ER for evaluation. LPN #176 verified she did not start an accident/incident investigation, completed a fall risk assessment, properly documented the fall in Resident #49's chart, and put an immediate intervention in place. LPN #176 stated she was behind on charting and focused on other assignments and could not complete the required tasks after Residents #49's fall. A subsequent interview on 12/01/25 at 9:46 A.M., the DON verified Resident #49 had a fall on 09/22/25 and the staff failed to complete a post-fall evaluation and implement any new fall interventions. Observation on 12/01/25 at 10:40 A.M. with Certified Nursing Assistant (CNA) #135, revealed Resident #49 was seated in her wheelchair next to her bed. Resident #49's call light was not within reach and was resting on the wall across the room and there were no non-skid fall strips next to Resident #49's bed per orders. Interview CNA #135 at the same time verified Resident #49's call light was located across the room from Resident #49 and rested on the switch on the wall and stated there should be non-skids strips on the floor. Subsequent interview on 12/01/25 at 11:58 P.M., the DON stated Resident #49 should always have her call light within reach to aid in the prevention of a fall. The DON stated Resident #49 had a room change recently and stated the staff forgot to apply the non- skid strips to the floor when the resident changed rooms. 2) Review of the medical record for Resident #39 revealed the resident was admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia, essential primary hypertension, peripheral vascular disease, dementia, insomnia, anxiety, anorexia, and chronic kidney disease. Review of the fall care plan for Resident #39 revised on 10/08/25, revealed the resident was at risk for falls related to her dementia diagnoses and diagnosis of anemia. Resident #39's fall interventions included fall risk assessment per facility protocol, anticipate the resident's needs, review falls and attempt to determine contributing factors, promote a safe environment, keep call light accessible, interdisciplinary team (IDT) to review falls for appropriate interventions, and follow the fall protocol if a fall occurs. Review of the MDS assessment dated [DATE], revealed Resident #39 was cognitively intact. Resident #39 was dependent on staff for ADLs and received Hospice services. Review of the progress note for Resident #39 dated 10/28/25 at 12:26 P.M., revealed the resident had an unwitnessed fall and was found on the floor parallel to Resident #39's bed. Resident #39 stated she tried to untangle her blankets on the bed and fell. Resident #39 had blood under right nostril, and the immediate intervention was to remind Resident #39 the importance of utilizing her call light when Resident #39 needed assistance. There was no documented evidence of a post-fall-evaluation completed for the resident after the fall on 10/28/25 at 12:26 P.M. Interview on 12/01/25 at 11:58 A.M., the DON verified the facility failed to complete a post fall evaluation after Resident #39's fall on 10/28/25. Review of the facility policy titled Accident and Incidents Protocol dated 08/2024 revealed the facility determined a fall or suspected fall was considered an incident/accident. A thorough investigation and follow-up would be completed as well as a summary of the accident. Accident/incident reports are initiated by a clinician as soon as the occurrence is discovered or reported. An accident/ incident report is an accurate and objective account of an occurrence. The staff was expected to document in the resident's medical chart the following facts, the date, time, person involved, where the accident/incident occurred, who first noticed the accident/incident, where the patient was positioned, assistance given, physician examination, and response of the family member at notification. This (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366209 If continuation sheet Page 2 of 4 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 12/01/2025 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)

F 0689 deficiency is a recite to the complaint survey completed 09/30/25. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366209 If continuation sheet Page 3 of 4 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 12/01/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Medical record review for Resident #15 revealed he was admitted to the facility on [DATE]. His diagnoses included hemiparesis/hemiplegia, Alzheimer's dementia with associated cognitive and decision-making impairments, peripheral vascular disease, and hypertension. Resident #15 required a guardian for his care. Resident #15 was ordered to be in Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes). 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. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366209 If continuation sheet Page 4 of 4