Inspection·September 22, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some applicable (N/A) on 08/29/25, left blank on 08/30/25, marked N/A on 09/01/25 and 09/03/25, left blank on 09/06/25 and 09/07/25, marked N/A on 09/08/25, left blank on 09/09/25 and 09/10/25, marked N/A on 09/11/25, left blank on 09/13/25, 09/14/25, and 09/15/25, marked N/A on 09/17/25, and left blank on 09/20/25 and 09/21/25. The restorative services for BUE exercises and cervical stretches were marked as not applicable (N/A) on 08/29/25, left blank on 08/30/25, marked N/A on 09/01/25, left blank on 09/06/25 and 09/07/25, marked N/A on 09/08/25, left blank on 09/09/25, 09/10/25, 09/13/25, 09/14/25, 09/15/25, and 09/16/25, marked N/A on 09/17/25, and left blank on 09/18/25, 09/19/25, 09/20/25, and 09/21/25. On 09/22/25 at 10:40 A.M., an interview with CNA #101 stated the facility did not have a restorative aide and she did not provide restorative services to residents due to not knowing what to do. CNA #101 further stated she was written up for marking N/A on the restorative documentation.On 09/22/25 at 11:27 A.M., an interview with Resident #3 stated staff did not perform any stretching exercises with her and she wished they would.On 09/22/25 at 11:32 A.M., an interview with Corporate Mobile DON stated the facility did have a restorative nursing program and that facility staff were inconsistent with providing restorative nursing. On 09/22/25 at 2:31 P.M., an interview with Regional Director of Clinical Services #104 verified CNA #101 was marking N/A on all restorative tasks for multiple residents and had been written up as a result. On 09/22/25 at 2:58 P.M., an interview with the Administrator verified the documentation for Resident #3's restorative services had multiple blanks and N/As, even after staff training on providing restorative services.On 09/22/25 at 4:10 P.M., an interview with Corporate Mobile DON verified restorative services continued to be marked N/A or left blank. Corporate Mobile DON claimed the majority of the staff documenting N/A in September 2025 were agency staff and further clarified that agency staff were still expected to provide restorative services as indicated in each resident's record.Review of the facility's job description for CNAs indicated resident care responsibilities included moving or assisting residents with moving to and from bed as necessary, transporting residents using wheelchairs, or assisting residents with walking as per the plan of care.2. Review of the medical record for Resident #10 revealed a re-admission date of 06/07/25 with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, weakness, and unsteadiness on feet.Review of the plan of care dated 08/13/25 revealed Resident #10 was at-risk for a decline in range of motion. Interventions included, but were not limited to: encourage resident participation (initiated 08/13/25); explain the program to the resident (initiated 08/13/25); monitor and document tolerance (initiated 08/13/25); monitor for signs and symptoms of discomfort and notify charge nurse (initiated 08/13/25); provide privacy and perform while resident was in bed or in chair (initiated 08/13/25); restorative to assess quarterly and as needed (PRN) (initiated 08/13/25). Further review revealed Resident #10 had impaired mobility skills related to ambulating. Interventions included, but were not limited to: apply good fitting non-skid footwear before ambulating (initiated 08/13/25); complete restorative assessments on admission, quarterly, and as needed (PRN) (initiated 08/13/25); document resident participation and progress PRN (initiated 08/13/25); encourage resident participation (initiated 08/13/25); encourage resident to stand up straight and maintain good body alignment and posture during ambulation (initiated 08/13/25); monitor resident for fatigue during ambulation (initiated 08/13/25); notify physician PRN (initiated 08/13/25); and praise all efforts and accomplishments (initiated 08/13/25).Review of the point of care tasks for Resident #10 revealed the following restorative services were to be provided every day on every shift: upper extremity and lower extremity dressing and grooming (initiated 08/13/25) and ambulate 100 feet with contact guard assist using wheeled walker with staff following with wheelchair (initiated 08/13/25).Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365874 If continuation sheet Page 2 of 5 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 365874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hudson Elms Nursing Center 563 W Streetsboro Road Hudson, OH 44236 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #10 had moderate cognitive impairment.Review of the facility's staff credentialing on restorative nursing services, dated 08/28/25, revealed Certified Nursing Assistants (CNAs) #101, #107, #108, #109, and #110 had been credentialed by Corporate Mobile Director of Nursing (DON).Review of the point of care documentation for August 2025 and September 2025 revealed the restorative services for ambulating Resident #10 were marked as not applicable (N/A) on 08/29/25, left blank on 08/30/25, marked N/A on 08/30/25, 09/01/25, 09/02/25, and 09/03/25, left blank on 09/05/25, 09/06/25, and 09/07/25, marked N/A on 09/08/25, left blank on 09/09/25 and 09/10/25, marked N/A on 09/11/25, and left blank 09/13/25, 09/14/25, 09/15/25, 09/20/25, and 09/21/25. The restorative services for dressing and grooming were marked N/A on 08/29/25, left blank on 08/30/25, marked N/A on 09/01/25 and 09/02/25, left blank on 09/05/25, 09/06/25, and 09/07/25, marked N/A on 09/08/25, and left blank on 09/09/25, 09/10/25, 09/13/25, 09/14/25, 09/15/25, 09/20/25, and 09/21/25.On 09/22/25 at 10:40 A.M., an interview with CNA #101 stated the facility did not have a restorative aide and she did not provide restorative services to residents due to not knowing what to do. CNA #101 further stated she was written up for marking N/A on the restorative documentation.On 09/22/25 at 11:32 A.M., an interview with Corporate Mobile DON stated the facility did have a restorative nursing program and that facility staff were inconsistent with providing restorative nursing. On 09/22/25 at 2:31 P.M., an interview with Regional Director of Clinical Services #104 verified CNA #101 was marking N/A on all restorative tasks for multiple residents and had been written up as a result. On 09/22/25 at 4:10 P.M., an interview with Corporate Mobile DON verified restorative services continued to be marked N/A or left blank. Corporate Mobile DON claimed the majority of the staff documenting N/A in September 2025 were agency staff and further clarified that agency staff were still expected to provide restorative services as indicated in each resident's record.On 09/22/25 at 4:54 P.M., an interview with Corporate Mobile DON verified the documentation for Resident #10's restorative services had multiple blanks and N/As, even after staff training on providing restorative services.Review of the facility's job description for CNAs indicated resident care responsibilities included moving or assisting residents with moving to and from bed as necessary, transporting residents using wheelchairs, or assisting residents with walking as per the plan of care.3. Review of the medical record for Resident #17 revealed an admission date of 11/08/23 with diagnoses including chronic obstructive pulmonary disease, muscle wasting and atrophy, hypertension, and Alzheimer's disease.Review of the point of care tasks for Resident #17 revealed the following restorative services were to be provided: assist with active range of motion (AROM) during activities of daily living (ADL) care, dressing and removing clothing to be completed every day on every shift (initiated 03/26/25), and assist with walking to and from dining using his walker or cane at breakfast, lunch, and dinner (initiated 03/26/25).Review of the therapy discharge notification form, dated 04/18/25, revealed Resident #17's occupational therapy would end on 04/22/25. A recommendation was made for restorative nursing for bilateral upper extremity (BUE) AROM exercises and wheeled walker mobility with contact guard assist.Review of the plan of care, initiated 04/14/25 and revised 05/28/25, revealed Resident #17 required a restorative dining program to maintain current function, walk to dining, and BUE AROM exercises. Interventions included, but were not limited to: encourage resident to do as much as possible (initiated 04/14/25); praise for all success (initiated 04/14/25); quarterly review of program via progress notes (initiated 04/14/25); restorative maintenance dining program six to seven times weekly (initiated 04/14/25); and assist with walking to and from dining using a cane or walker (initiated 03/26/25, revised 09/04/25).Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had severe cognitive impairment.Review of the facility's staff credentialing on restorative nursing services, dated 08/28/25, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365874 If continuation sheet Page 3 of 5 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 365874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hudson Elms Nursing Center 563 W Streetsboro Road Hudson, OH 44236 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed Certified Nursing Assistants (CNAs) #101, #107, #108, #109, and #110 had been credentialed by Corporate Mobile Director of Nursing (DON).Review of the point of care documentation for August 2025 and September 2025 revealed the restorative services for AROM during ADL care for Resident #17 were marked as not applicable (N/A) on 08/29/25, left blank on 08/30/25, marked as N/A on 08/31/25 and 09/01/25, left blank on 09/02/25 and 09/05/25, marked N/A on 09/07/25, and left blank on 09/08/25, 09/13/25, 09/20/25, and 09/21/25. The restorative services for walking to dining were marked as N/A for all three meals on 08/29/25, left blank for all three shifts on 08/30/25, marked as N/A for breakfast and dinner on 08/31/25, marked as N/A for all three meals on 09/01/25, left blank for all three meals on 09/02/25, left blank for lunch and dinner on 09/03/25, left blank for all three meals on 09/05/25, left blank for dinner on 09/06/25, marked as N/A for all three meals on 09/07/25, left blank for all three meals on 09/08/25, marked as N/A for dinner on 09/11/25, left blank for dinner on 09/12/25, and left blank for all three meals on 09/13/25.On 09/22/25 at 10:40 A.M., an interview with CNA #101 stated the facility did not have a restorative aide and she did not provide restorative services to residents due to not knowing what to do. CNA #101 further stated she was written up for marking N/A on the restorative documentation.On 09/22/25 at 11:32 A.M., an interview with Corporate Mobile DON stated the facility did have a restorative nursing program and that facility staff were inconsistent with providing restorative nursing. On 09/22/25 at 2:31 P.M., an interview with Regional Director of Clinical Services #104 verified CNA #101 was marking N/A on all restorative tasks for multiple residents and had been written up as a result. On 09/22/25 at 4:10 P.M., an interview with Corporate Mobile DON verified restorative services continued to be marked N/A or left blank. Corporate Mobile DON claimed the majority of the staff documenting N/A in September 2025 were agency staff and further clarified that agency staff were still expected to provide restorative services as indicated in each resident's record.On 09/22/25 at 4:54 P.M., an interview with Corporate Mobile DON verified the documentation for Resident #17's restorative services had multiple blanks and N/As, even after staff training on providing restorative services.Review of the facility's job description for CNAs indicated resident care responsibilities included moving or assisting residents with moving to and from bed as necessary, transporting residents using wheelchairs, or assisting residents with walking as per the plan of care.4. Review of the medical record for Resident #37 revealed a re-admission date of 07/30/24 with diagnoses including unsteadiness on feet, weakness, dementia, hypertension, and muscle weakness.Review of the plan of care revised 05/31/25 revealed Resident #37 had an alteration in activities of daily living (ADL) performance and participation. Interventions included, but were not limited to: encourage resident participation while performing ADLs (initiated 05/31/25); notify nursing of complaints of pain or discomfort (initiated 05/31/25); provide necessary adaptive equipment to meet daily needs (initiated 05/31/25); and staff to anticipate needs and assist as needed (PRN) (initiated 05/31/25).Review of the point of care tasks for Resident #10 revealed the following restorative services were to be provided every day on every shift: active range of motion (AROM) to bilateral upper extremities (BUE) in order to maintain ROM and increase ADL performance (initiated 06/09/25), standby assist at meals with setup using divided plate and two handled cup for all liquids (initiated 06/09/25), and passive range of motion (PROM) exercises to bilateral hands to maintain ROM and increased ADL performance (initiated 06/09/25).Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had severe cognitive impairment.Review of the facility's staff credentialing on restorative nursing services, dated 08/28/25, revealed Certified Nursing Assistants (CNAs) #101, #107, #108, #109, and #110 had been credentialed by Corporate Mobile Director of Nursing (DON).Review of the point of care documentation for August 2025 and September 2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365874 If continuation sheet Page 4 of 5 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 365874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hudson Elms Nursing Center 563 W Streetsboro Road Hudson, OH 44236 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete revealed the restorative services for AROM to BUE for Resident #37 were left blank on 08/29/25, marked as not applicable (N/A) on 08/31/25, left blank on 09/02/25, 09/03/25, 09/06/25, 09/07/25, 09/09/25, and 09/10/25, marked N/A on 09/11/25 and 09/12/25, and left blank on 09/13/25, 09/14/25, and 09/18/25. The restorative services for dining were left blank on 08/29/25, marked N/A on 08/31/25, left blank 09/02/25, 09/03/25, 09/06/25, 09/07/25, 09/09/25, and 09/10/25, marked as N/A on 09/11/25 and 09/12/25, and left blank on 09/13/25 and 09/14/25. The restorative services for PROM to bilateral hands were left blank on 08/29/25, marked N/A on 08/31/25, left blank on 09/02/25, 09/03/25, 09/06/25, 09/07/25, 09/09/25, and 09/10/25, marked N/A on 09/11/25 and 09/12/25, and left blank on 09/13/25, 09/14/25, and 09/18/25.On 09/22/25 at 10:40 A.M., an interview with CNA #101 stated the facility did not have a restorative aide and she did not provide restorative services to residents due to not knowing what to do. CNA #101 further stated she was written up for marking N/A on the restorative documentation.On 09/22/25 at 11:32 A.M., an interview with Corporate Mobile DON stated the facility did have a restorative nursing program and that facility staff were inconsistent with providing restorative nursing. On 09/22/25 at 2:31 P.M., an interview with Regional Director of Clinical Services #104 verified CNA #101 was marking N/A on all restorative tasks for multiple residents and had been written up as a result. On 09/22/25 at 4:10 P.M., an interview with Corporate Mobile DON verified restorative services continued to be marked N/A or left blank. Corporate Mobile DON claimed the majority of the staff documenting N/A in September 2025 were agency staff and further clarified that agency staff were still expected to provide restorative services as indicated in each resident's record.On 09/22/25 at 4:54 P.M., an interview with Corporate Mobile DON verified the documentation for Resident #37's restorative services had multiple blanks and N/As, even after staff training on providing restorative services.Review of the facility's job description for CNAs indicated resident care responsibilities included moving or assisting residents with moving to and from bed as necessary, transporting residents using wheelchairs, or assisting residents with walking as per the plan of care.This deficiency represents non-compliance investigated under Complaint Number 2610571. Event ID: Facility ID: 365874 If continuation sheet Page 5 of 5