Inspection Reports for Woods Edge Rehab and Nursing
1171 Towne St, Cincinnati, OH 45216, OH, 45216
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 1, 2025, identified deficiencies related to fall investigations and infection control practices during wound care. Earlier inspections showed a pattern of issues including inadequate supervision leading to resident elopements, medication documentation errors, food service and labeling problems, and lapses in staff registration and infection control. Complaint investigations substantiated concerns about supervision failures that resulted in injury and infection control deficiencies, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaints were substantiated, particularly those involving resident safety and infection control. The facility’s inspection history indicates ongoing challenges with supervision and infection control, with no clear trend of improvement or worsening in recent reports.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
10.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
130% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
75 residents
Based on a December 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 2
Date: Dec 1, 2025
Visit Reason
The inspection was conducted to investigate complaints related to inadequate fall investigations, documentation, and infection control practices during wound care at Woods Edge Rehab and Nursing.
Complaint Details
The complaint survey completed on 09/30/25 cited deficiencies related to fall investigations and infection control practices. The facility failed to complete thorough investigations and documentation for falls involving Residents #39 and #49, and failed to follow infection control protocols during wound care for Resident #15.
Findings
The facility failed to ensure thorough investigations and proper documentation of resident falls, including post-fall evaluations and implementation of immediate interventions. Additionally, infection control techniques during wound care were not properly maintained, including failure to follow hand hygiene and PPE protocols.
Deficiencies (2)
Failed to ensure a resident's falls were thoroughly investigated, properly documented, a fall risk assessment and post-fall evaluation were completed, and immediate fall interventions were implemented.
Failed to ensure infection control techniques were properly maintained during wound care, including improper hand hygiene and PPE use.
Report Facts
Facility census: 75
Falls reviewed: 3
Residents affected by fall deficiencies: 2
Residents reviewed for wound care: 3
Residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #176 | Licensed Practical Nurse | Failed to document fall and complete fall risk assessment and post-fall evaluation for Resident #49 |
| LPN #174 | Licensed Practical Nurse | Failed to follow proper hand hygiene and PPE protocols during wound care for Resident #15 |
| LPN #106 | Licensed Practical Nurse | Participated in wound care observation for Resident #15 |
| Director of Nursing | Director of Nursing | Verified failures in fall investigations and infection control practices |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 75
Deficiencies: 2
Date: Sep 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision and failure to prevent elopement of Resident #11, who exited the secured building by jumping out of a second story window, resulting in injury.
Complaint Details
The complaint investigation was triggered by an incident where Resident #11 eloped by jumping out of a second story window, resulting in an open fracture. The facility was found noncompliant under Complaint Number 2614502. The investigation included medical record review, staff interviews, and review of facility policies. The Immediate Jeopardy was removed after corrective actions were implemented, but the facility remained out of compliance at Severity Level 2.
Findings
The facility failed to provide adequate supervision and timely interventions for exit-seeking behaviors for Resident #11, resulting in immediate jeopardy and serious injury. Additionally, infection control deficiencies were found related to improper wound care techniques for Resident #15.
Deficiencies (2)
Failure to provide adequate supervision and timely interventions for exit-seeking behaviors for Resident #11, resulting in immediate jeopardy and injury from elopement.
Failure to ensure proper infection control techniques during wound care for Resident #15, including improper hand hygiene and PPE use.
Report Facts
Residents at risk for elopement: 18
Facility census: 74
Facility total capacity: 75
Resident #11 weight: 219
Resident #11 height: 70
Incident time: 13.59
Window jump height: 15
Facility census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #205 | Licensed Practical Nurse | Unit nurse at time of Resident #11 incident; failed to assess resident and was terminated after investigation. |
| Director of Nursing | Director of Nursing (DON) | Involved in corrective actions, staff education, and investigation of Resident #11 incident. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Participated in staff education, assessments, and ongoing monitoring related to Resident #11 incident. |
| Maintenance Director | Maintenance Director (MD) | Audited second-floor windows for security after Resident #11 incident. |
| Administrator | Facility Administrator | Notified of incident, involved in investigation and corrective actions for Resident #11 incident. |
| Regional Clinical Officer | Regional Clinical Officer (RCO) #800 | Provided re-education and oversight related to Resident #11 incident investigation. |
| LPN #106 | Licensed Practical Nurse | Involved in wound care observation for Resident #15. |
| LPN #174 | Licensed Practical Nurse | Performed wound care on Resident #15 with improper infection control techniques. |
| Certified Nursing Assistant #120 | Certified Nursing Assistant (CNA) | Assisted with wound care for Resident #15. |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication administration documentation discrepancies for Resident #13.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00163953.
Findings
The facility failed to ensure that administration of a narcotic pain medication (morphine sulfate solution) was properly documented on the medication administration record (MAR) for Resident #13. Discrepancies were found between the controlled drug records and the MAR for multiple dates in September, October, and December 2024.
Deficiencies (1)
Failed to ensure administration of a narcotic pain medication was documented on the medication administration record.
Report Facts
Facility census: 83
Residents reviewed for medication administration documentation: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Verified medication administration and documentation discrepancies for Resident #13. |
| Licensed Practical Nurse (LPN) #405 | Documented one dose of morphine on 09/27/24. | |
| Licensed Practical Nurse (LPN) #410 | Documented doses of morphine on 10/03/24 and 10/08/24. | |
| Licensed Practical Nurse (LPN) #420 | Documented dose of morphine on 12/23/24. |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Date: Mar 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's food labeling practices.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00162926.
Findings
The facility failed to properly label prepared foods in the refrigerator, including trays of sandwiches, bowls of mandarin oranges, and cups of juice, which could potentially affect all residents receiving food from the kitchen.
Deficiencies (1)
Facility failed to properly label prepared foods in the refrigerator.
Report Facts
Facility census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kitchen Supervisor (KS) #43 | Interviewed regarding unlabeled food items in the refrigerator |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Date: Nov 5, 2024
Visit Reason
The inspection was conducted following complaints regarding inadequate supervision leading to the elopement of a resident and failure to serve specialized diets as planned by the Registered Dietitian.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00158767 and Complaint Number OH00158338.
Findings
The facility failed to provide adequate supervision to prevent the elopement of Resident #59, who left the secured unit and was returned by police without injury. Additionally, the facility failed to serve specialized diets as planned, affecting 15 residents who did not receive the correct food textures or vegetables as ordered.
Deficiencies (2)
Failed to provide adequate supervision to prevent the elopement of one resident (#59) from a secured unit.
Failed to serve specialized diets as planned by the Registered Dietitian, affecting 15 residents who did not receive the correct puree or mechanical soft food textures or vegetables.
Report Facts
Residents affected: 1
Residents affected: 15
Facility census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #500 | Licensed Practical Nurse | Named in elopement incident and witness statement |
| State Tested Nurse Aide #216 | State Tested Nurse Aide | Named in elopement incident and witness statement |
| Assistant Director of Nursing #304 | Assistant Director of Nursing | Conducted elopement investigation and interview |
| Registered Dietitian #600 | Registered Dietitian | Verified diet spreadsheet and diet service failures |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 6
Date: Jun 7, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to multiple concerns including resident dignity during feeding, application of compression stockings, physician visits, menu adherence, food quality, and employee compliance with hairnet policies.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00153742.
Findings
The facility was found deficient in ensuring residents were fed with dignity, compression stockings were applied as ordered, residents were seen by physicians as required, menus were followed and residents notified of changes, food was prepared according to recipes and visually appealing, and employees wore hairnets properly during food preparation and service. These deficiencies affected multiple residents and had potential for harm.
Deficiencies (6)
Failed to ensure residents were fed in a safe and dignified manner, specifically feeding Resident #64 while standing and not facing the resident.
Failed to ensure Resident #80's compression stockings were applied as ordered to treat edema.
Failed to ensure Resident #80 was seen by the physician as required during the first 90 days of admission.
Failed to ensure menus were followed and residents notified of menu changes prior to meals, affecting 88 of 89 residents.
Failed to ensure food was prepared according to recipes and was visually appealing, affecting 88 of 89 residents.
Failed to ensure employees wore hairnets properly while preparing and serving food and beverages, affecting 88 of 89 residents.
Report Facts
Facility census: 89
Residents affected: 1
Residents affected: 1
Residents affected: 88
Residents affected: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #300 | State Tested Nursing Assistant | Named in feeding dignity deficiency for Resident #64 |
| LPN #400 | Licensed Practical Nurse | Named in compression stocking deficiency for Resident #80 |
| Director of Nursing | Director of Nursing (DON) | Verified physician visit deficiency for Resident #80 |
| Medical Director #420 | Medical Director | Verified physician visit deficiency for Resident #80 |
| Dietary Supervisor #405 | Dietary Supervisor | Verified menu, food preparation, and hairnet deficiencies |
| Dietary Aide #415 | Dietary Aide | Observed not wearing hairnet properly |
| Dietary [NAME] #430 | Dietary Cook | Observed not wearing hairnet properly |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Date: Mar 26, 2024
Visit Reason
The inspection was conducted due to complaints regarding food service safety and environmental cleanliness at the facility.
Complaint Details
This deficiency represents noncompliance investigated under Complaint Number OH00151129 for food service safety and Complaint Numbers OH00151129 and OH00151838 for environmental cleanliness.
Findings
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, with staff not properly wearing hairnets. Additionally, the facility failed to maintain a clean, sanitary, and homelike environment, evidenced by roach infestations in a resident's room.
Deficiencies (2)
Failure to procure food from approved sources and failure to store, prepare, distribute, and serve food in accordance with professional standards, including staff not wearing hairnets properly.
Failure to provide a clean, sanitary, and homelike environment, with evidence of roaches in a resident's room.
Report Facts
Facility census: 86
Residents affected: 1
Residents affected: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admissions Director | Interviewed regarding kitchen staff not wearing hairnets | |
| Kitchen Director | Interviewed regarding kitchen staff hairnet compliance and resident food service | |
| Licensed Practical Nurse (LPN) #66 | Reported ongoing roach problems and pest control practices |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Date: Nov 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to ensure a state tested nursing assistant's (STNA) registration was current and not expired.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00146811.
Findings
The facility failed to ensure that STNA #10's nurse aide registration was current, affecting one of three personnel files reviewed and potentially impacting sixteen residents regularly cared for by this aide. The facility census was 86.
Deficiencies (1)
Failed to ensure a state tested nursing assistant's (STNA) registration was not expired, affecting one STNA and potentially sixteen residents.
Report Facts
Facility census: 86
Residents affected: 16
Personnel files reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resources (HR) #60 | Interviewed regarding awareness of STNA #10's nurse aide registry expiration and follow-up actions | |
| Director of Nursing (DON) | Confirmed facility responsibility for submitting information to the State of Ohio Nurse Aide Registry and STNA #10's assigned work area |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Date: Aug 11, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to conduct a timely post-fall investigation for Resident #76.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00144308.
Findings
The facility failed to conduct a post-fall investigation within the required 24 hours, completing it 13 days after Resident #76's fall on 07/25/23. The resident had an unwitnessed fall, was treated for a urinary tract infection suspected as a predisposing factor, and had no further falls since.
Deficiencies (1)
Failure to conduct a timely post-fall investigation for Resident #76.
Report Facts
Days delay in post-fall investigation: 13
Residents reviewed for falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed the delay in conducting the post-fall investigation for Resident #76. |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: Jun 23, 2023
Visit Reason
The inspection was conducted as a complaint investigation focusing on the facility's failure to ensure resident call lights were within reach as per the plan of care.
Complaint Details
This deficiency is based on incidental findings discovered during the course of this complaint investigation.
Findings
The facility failed to ensure call lights were within reach for residents #19 and #20, both non-ambulatory and cognitively impaired, which was confirmed by observations and staff interviews. Additionally, the facility lacked a call light policy and failed to have a registered nurse on duty for eight consecutive hours on multiple days in June 2023.
Deficiencies (2)
Failure to ensure resident call lights were within reach per the plan of care for residents #19 and #20.
Failure to have a registered nurse working in the facility for eight consecutive hours daily as required.
Report Facts
Facility census: 87
Dates without RN coverage: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #625 | State Tested Nursing Assistant | Confirmed call lights were out of reach for residents #19 and #20 and discussed observations with surveyor |
| RN #630 | Assistant Director of Nursing (ADON), Registered Nurse | Confirmed lack of call light policy and RN staffing deficiencies |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 7
Date: Feb 9, 2023
Visit Reason
The inspection was conducted as a standard regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to provide meals on proper plates, failure to provide required Medicare notices to residents, inadequate assistance with activities of daily living, lack of resident activities, insufficient RN coverage, failure to accommodate resident food preferences, and unsanitary kitchen conditions with improper dishwasher temperatures.
Deficiencies (7)
Residents were served meals on disposable Styrofoam plates due to lack of regular plates and plate covers.
Failure to provide Notice of Medicare Non Coverage (NOMNC) or Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) to residents upon Medicare coverage changes.
Failure to provide daily activities of daily living (ADL) such as hair care, hygiene, dressing, and getting out of bed for one resident.
Failure to provide activities to meet residents' needs for two residents.
Failure to ensure Registered Nurse coverage for eight consecutive hours seven days a week.
Failure to provide Lactaid milk as a food preference for one resident due to supplier shortage.
Failure to maintain kitchen sanitation, improper dishwasher temperature, expired food items, and food contamination risks.
Report Facts
Residents affected: 24
Facility census: 79
Residents reviewed for beneficiary notices: 3
Residents reviewed for ADL: 23
Residents reviewed for activities: 3
Days without RN coverage: 3
Residents affected by lack of activities: 2
Residents affected by food preference issue: 1
Dishwasher temperature: 60
Facility dishwasher required temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide #25 | Dietary Aide | Verified not wearing hair net and dishwasher not working properly. |
| Dietary Supervisor #77 | Dietary Supervisor | Verified use of Styrofoam plates and kitchen supply issues. |
| Administrator | Administrator | Verified lack of RN coverage on specific dates and Medicare notice issues. |
| Social Service Designee #60 | Social Service Designee | Verified Medicare notice deficiencies for residents. |
| State Tested Nursing Aide #201 | STNA | Reported resident combative behavior and refusal of care. |
| Licensed Practical Nurse #80 | LPN | Reported resident behavior and verified absence of Lactaid milk on tray. |
| Activity Director | Activity Director | Verified lack of resident participation in activities. |
| Registered Dietician #14 | Registered Dietician | Reported resident should receive Lactaid milk with every meal. |
| Dietary Manager #97 | Dietary Manager | Reported supplier out of Lactaid milk and no alternative sought. |
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 13
Date: Jun 13, 2019
Visit Reason
The inspection was conducted as part of the annual survey of Woods Edge Rehab and Nursing to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to have call lights within reach for residents, inadequate access to personal funds on weekends, incomplete documentation of Do Not Resuscitate (DNR) orders, failure to notify residents and ombudsman in writing about transfers, inaccurate Minimum Data Set (MDS) discharge coding, lack of baseline and comprehensive care plans within required timeframes, failure to develop and revise fall risk care plans, unsafe room conditions, and improper management of psychotropic medication orders.
Deficiencies (13)
Failed to have call lights in easy reach for resident #80.
Failed to provide residents access to their money on weekends affecting residents #14, #41, and #50.
Failed to ensure resident's Do Not Resuscitate (DNR) code statuses were documented on a valid form for resident #6.
Failed to provide timely written notification to residents and ombudsman before transfer or discharge for residents #29, #41, and #78.
Failed to ensure accurate discharge status on MDS assessment for resident #89.
Failed to develop accurate baseline care plans within 48 hours of admission for residents #41, #57, and #84.
Failed to develop and implement care plans meeting residents' needs, including fall risk care plan for residents #2, #27, #80, and #15.
Failed to develop the complete care plan within 7 days and review with interdisciplinary team for residents #6 and #15.
Failed to ensure fall risk care plan was reviewed and revised and residents allowed to participate in care planning for residents #6, #13, and #15.
Failed to ensure fall risk interventions were implemented and failed to transfer resident based on assessed transfer needs resulting in a fall for residents #13 and #15.
Failed to ensure psychotropic medication ordered on PRN basis was not prescribed for an indefinite period for resident #44.
Failed to ensure resident #2's hospice provider documentation was accurate in the medical record.
Failed to ensure resident #27 was provided a safe and functional room; headboard was detached and curtains partially detached.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #30 | Licensed Practical Nurse | Verified no call light was in reach of Resident #80 |
| Licensed Practical Nurse (LPN) #119 | Licensed Practical Nurse | Verified no completed Ohio DNR Identification form for Resident #6 |
| Director of Nursing (DON) | Director of Nursing | Verified multiple deficiencies including lack of DNR form, failure to notify residents and ombudsman, and fall risk care plan issues |
| Activities Supervisor #13 | Activities Supervisor | Stated activities personnel do not handle resident petty cash funds on weekends |
| Administrator | Administrator | Verified failure to notify ombudsman, inaccurate MDS discharge coding, lack of baseline care plans, and psychotropic medication issues |
| Director of Nursing (DON) #26 | Director of Nursing | Verified lack of baseline care plans for Resident #57 |
| Licensed Practice Nurse (LPN) #65 | Licensed Practical Nurse | Verified lack of fall mats in care plan and resident behavior regarding headboard removal |
| Resident #15 | Resident | Reported fall due to standing lift misuse |
| Social Service Director (SSD) #116 | Social Service Director | Verified no care conference held or invitation to resident #15 and #6 |
| Physical Therapy Assistant (PTA) #105 | Physical Therapy Assistant | Stated no assessment for standing lift use for Resident #15 prior to fall |
| Therapy Manager (TM) #21 | Therapy Manager | Verified no recommendation for mechanical lift use for Resident #15 |
| State Tested Nursing Aide (STNA) #120 | State Tested Nursing Aide | Verified headboard off bed and curtains partially detached in Resident #27's room |
Inspection Report
Routine
Census: 79
Capacity: 80
Deficiencies: 13
Date: May 17, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, financial management, care planning, infection control, staffing, and safety in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure dignified care, proper management of resident funds, accurate resident assessments, care plan participation, infection control practices, nurse aide training and performance reviews, and posting of nurse staffing information.
Deficiencies (13)
Failed to ensure a resident was cared for in a dignified manner due to an uncovered window in the resident's door during perineal care.
Failed to ensure written authorizations for resident funds were completed for one resident fund account.
Failed to provide quarterly statements upon request and quarterly to residents for resident fund accounts.
Failed to provide spend down notification to residents within $200 of Medicaid limit and failed to convey personal resident funds upon death.
Failed to ensure advance directives were listed correctly in resident's hard and electronic charts.
Failed to provide a resident with the right to a demand bill when discontinued from Medicare coverage.
Failed to provide written bed hold notices to residents when hospitalized.
Failed to ensure resident assessments were completed accurately, specifically the Resident Mood Interview was not conducted when required.
Failed to ensure residents or their representatives were given the opportunity to participate in the development, review, and revision of their care plans.
Failed to place no smoking signs in areas where oxygen is stored and in use.
Failed to ensure nurse aides received 12 hours of training annually and annual performance reviews.
Failed to update nurse staffing information daily on the facility bulletin board.
Failed to ensure staff appropriately handled wound care supplies to prevent potential transmission of organisms.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Nurse aides affected: 3
Residents affected: 80
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Verified uncovered window in Resident #12's door affecting dignity |
| Administrator #55 | Administrator | Verified missing written authorization for Resident #70's funds and missing quarterly statements for Resident #15 |
| Licensed Practical Nurse #89 | Licensed Practical Nurse | Verified advance directive discrepancy for Resident #18 |
| Social Services Aide #45 | Social Services Aide | Verified missing SNF ABN for Resident #74 and care plan conference offerings |
| Admissions Director #67 | Admissions Director | Verified missing bed hold notice for Resident #60 |
| MDS Nurse #52 | MDS Nurse | Verified incomplete Resident Mood Interview for Resident #60 |
| Social Service Director #45 | Social Service Director | Verified lack of care plan participation documentation for Residents #71 and #76 |
| Registered Nurse #13 | Registered Nurse | Verified missing no smoking oxygen signs in Resident #38's room |
| Human Resources Manager #5 | Human Resources Manager | Verified nurse aides received less than required training and missing performance reviews |
| Registered Nurse #200 | Registered Nurse | Verified outdated nurse staffing posting |
| Licensed Practical Nurse #81 | Licensed Practical Nurse | Observed improper handling of wound care supplies for Resident #60 |
| Director of Nursing | Director of Nursing | Reported care conferences offered quarterly but no policy exists |
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