Health inspection·May 5, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident #99's incontinence care was provided timely. This finding affected one (Resident #99) of three residents reviewed for incontinence care. Residents Affected - Few Findings include: Review of Resident #99's medical record revealed she was admitted on [DATE] with diagnoses including cerebrovascular accident and hospice services. Review of Resident #99's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited intact cognition and required extensive two person assist for bed mobility, dressing and toilet use. She required extensive one person assist with eating. She appeared to have a decline as she was not interviewable. Review of Resident #99's physician orders revealed an order dated 02/16/23 for every two hour checks for resident safety person. Review of the medication administration records (MARS) and treatment administration records (TARS) from 04/01/23 to 04/30/23 revealed the nursing staff documented that the safety checks were completed every two hours. Interview on 05/05/23 at 6:33 A.M. with State Tested Nursing Assistant (STNA) #804 indicated about a week ago STNA #805 had Resident #99 and she switched rooms with Agency STNA #806 to help another staff member. STNA #804 stated apparently Agency STNA #806 did not change Resident #99 all night and it was evident to dayshift staff. She stated STNA #807 who worked dayshift took a picture of the resident's bed linens and sent the picture to the resident's son. She confirmed STNA #805 was suspended for three days even though Agency STNA #806 actually had the resident. Telephone interview on 05/05/23 at 9:47 A.M. with STNA #807 indicated on a unknown date, she came in and provided care to Resident #99. She stated the residents on the entire hall were soaked with urine. She stated Resident #99's bed pad and clothing were saturated with urine. She felt the resident was not provided incontinent care the entire night. She stated she took a picture of the bedpad and showed it to her co-worker when Resident #99's son came up behind her and saw the picture on her phone. She stated he became upset because the resident was not provided timely incontinence care. Interview on 05/05/23 at 10:02 A.M. with the Administrator indicated it was brought to his attention that STNA #805 did not provide timely incontinence care to Resident #99 on 04/15/23. He stated it was also brought to his attention that STNA #807 took a picture of Resident #99's incontinence pad when she came in on the morning shift on 04/15/23 and then forwarded the picture to Resident #99's family member. He stated he educated STNA #805 on providing timely incontinence care and had her do return demonstrations with senior staff. He indicated he also educated STNA #807 who took the picture of Resident #99's pad which was against their policy. Telephone interview on 05/05/23 at 10:59 A.M. with STNA #805 indicated she worked on 04/15/23 from 7:00 P.M. to 7:00 A.M. and was on the split. She stated she switched Resident #99's room with Agency STNA #806 and that STNA was to provide her care. She stated the Administrator wrote her up for attendance and gave her education on providing resident care. She stated she was unaware of the incident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366434 If continuation sheet Page 2 of 3 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 366434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hudson Springs Nursing and Rehab 5000 Sowul Boulevard Stow, OH 44224 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with Resident #99 until another STNA told her that pictures of the resident's bed linens were sent to the resident's family member. Review of the Perineal Care policy revised 11/2019 indicated it was the facility policy to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. This deficiency represents non-compliance investigated under Complaint Number OH00142198. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366434 If continuation sheet Page 3 of 3