Health inspection·June 16, 2023

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to timely notify Resident #44's family and physician of an injury to the right lower leg. This finding affected one (Resident #44) of three residents reviewed for injuries. Findings include: Review of Resident #44's medical record revealed she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia and dysphagia oral phase. Review of Resident #44's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited a memory problem. Review of Resident #44's progress notes revealed a note dated 05/15/23 at 9:25 A.M. authored by Licensed Practical Nurse (LPN) #833 indicated she had a large lump on her right shin below her knee which was tender to the touch. The area was reported to hospice services and the DON. The son was notified of the right leg lump and was told she bumped her leg on the hoyer lift when going back to bed on Friday (05/12/23) night. Review of Resident #44's Witness Statement Form dated 05/21/23 authored by LPN #833 revealed on 05/15/23 she had received in report from the night nurse, RN (Registered Nurse) #881 at approximately 5:50 A.M., that Resident #44 had a bump on her right leg. The statement stated RN #881 reported Resident #44 bumped it on the Hoyer mechanical lift when the staff put her to bed and that she gave her a dose of morphine for pain. The area was assessed on her right inner calf below knee and the DON (Director of Nursing), physician and hospice were notified. X-rays were done to the area which was raised and tender with palpation. The son was made aware. Observation on 06/14/23 at 9:58 A.M. with LPN #833 of Resident #44's right lower leg revealed an egg sized lump on her inner right mid leg with yellow, green and purple bruising on the top, side and back of her leg. The resident was not interviewable. Interview on 06/14/23 at 2:21 P.M. with the Administrator confirmed RN #881 did not document in Resident #44's medical record on 05/12/23 about the injury to her right lower leg, did not call the physician and did not notify the family of the injury. Review of the Change in a Resident's Condition or Status policy dated 11/16 indicated it was the facility's policy to ensure the resident's attending physician and the resident's authorized Page 1 of 7 366434 366434 06/16/2023 Hudson Springs Nursing and Rehab 5000 Sowul Boulevard Stow, OH 44224

F 0559 Level of Harm - Minimal harm or potential for actual harm representative or interested family member were notified of changes in the resident's physical, mental, or psychosocial status. The deficiency is an incidental finding discovered during the course of the complaint investigation. Residents Affected - Few 366434 Page 2 of 7 366434 06/16/2023 Hudson Springs Nursing and Rehab 5000 Sowul Boulevard Stow, OH 44224

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #73's vital signs were obtained per the physician's order and failed to ensure Resident #44's injury to her right lower leg was assessed timely. This finding affected two (Residents #44 and #73) of three residents reviewed for injuries. Residents Affected - Few Findings include: 1. Review of Resident #73's medical record revealed she was admitted on [DATE] and expired on [DATE] with diagnoses including encounter for other orthopedic aftercare, presence of left artificial knee joint and anxiety disorder. Review of Resident #73's Minimum Data Assessment (MDS) 3.0 assessment dated [DATE] revealed she exhibited intact cognition. Review of Resident #73's physician orders revealed an order dated [DATE] for vital signs once a day every shift and an order dated [DATE] to monitor the resident for signs of worsening heart failure every shift. Review of Resident #73's medical record revealed admission vital signs were obtained on [DATE] which included a temperature of 97 degrees Fahrenheit, a pulse of 61 beats per minute (BPM), respirations of 18 per minute, a blood pressure (BP) of 144/67 and oxygen saturation of 96% on room air. No other vital signs were obtained on [DATE] and [DATE]. She was transferred to the emergency room on [DATE] and expired at that time. Review of Resident #73's Physician Progress Note form dated [DATE] revealed the vital signs were documented as the BP 144/67, pulse 61, respirations 18 and oxygen level 96%. The documentation included the vital signs obtained from Resident #73's medical record on [DATE]. Interview on [DATE] at 2:44 P.M. with Registered Nurse (RN) Regional #884 confirmed Resident #73's vitals were not taken per physician orders and the physician progress note dated [DATE] contained the same vital signs obtained by the nurse dated [DATE]. 2. Review of Resident #44's medical record revealed she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia and dysphagia oral phase. Review of Resident #44's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited a memory problem. Review of Resident #44's undated Witness Statement Form authored by State Tested Nursing Assistant (STNA) #818 indicated on [DATE], STNA #819 and STNA #818 were putting the resident to bed. As the staff were trying to take her pants off, she sat straight up in bed and grabbed her right leg. When her pants were removed, her whole knee was swollen half way down her leg and it was reported to Registered Nurse (RN) #881. Review of Resident #44's undated Witness Statement Form authored by STNA #819 indicated on [DATE] the staff noticed a large lump on the resident's right lower leg and the nurse (RN #881) was notified. 366434 Page 3 of 7 366434 06/16/2023 Hudson Springs Nursing and Rehab 5000 Sowul Boulevard Stow, OH 44224

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on [DATE] at 9:52 A.M. with Licensed Practical Nurse (LPN) #833 indicated she worked dayshift on [DATE] and had observed a large lump on Resident #44's right lower leg with bruising. She stated she got in report from the nightshift nurse that the resident had bumped her leg on a Hoyer mechanical lift during a transfer. She could not remember the name of the nightshift nurse who gave her the report. Observation on [DATE] at 9:58 A.M. with LPN #833 of Resident #44's right lower leg revealed an egg sized lump on her inner right mid leg with yellow, green and purple bruising on the top, side and back of her leg. The resident was not interviewable. Interview on [DATE] at 2:21 P.M. with the Administrator confirmed Resident #44's medical record did not have evidence an assessment of the resident was completed timely following a report of an injury to her right lower leg on [DATE]. The medical record revealed the assessment for Resident #44's right lower leg injury was completed on [DATE]. This deficiency represents non-compliance investigated under Complaint Number OH00143277. 366434 Page 4 of 7 366434 06/16/2023 Hudson Springs Nursing and Rehab 5000 Sowul Boulevard Stow, OH 44224

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a timely and thorough investigation was completed for Resident #44's injury to her right lower leg. This finding affected one (Resident #44) of three residents reviewed for injuries. Findings include: Review of Resident #44's medical record revealed she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia and dysphagia oral phase. Review of Resident #44's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited a memory problem. Review of Resident #44's physician orders revealed an order dated 07/24/20 which indicated she may be up in a wheelchair as tolerated, an order dated 11/13/21 to admit to hospice services and an order dated 10/04/22 which indicated she was a dependent assist of two with a mechanical lift/hoyer. Review of Resident #44's undated Witness Statement Form authored by State Tested Nursing Assistant (STNA) #818 indicated on 05/13/23, STNA #819 and STNA #818 were putting the resident to bed. As the staff were trying to take her pants off, she sat straight up in bed and grabbed her right leg. When her pants were removed, her whole knee was swollen half way down her leg and it was reported to Registered Nurse (RN) #881. Review of Resident #44's undated Witness Statement Form authored by STNA #819 indicated on 05/13/23 the staff noticed a large lump on the resident's right lower leg and the nurse (RN #881) was notified. Review of Resident #44's progress notes revealed a note dated 05/15/23 at 9:25 A.M. authored by Licensed Practical Nurse (LPN) #833 which indicated she had a large lump on her right shin below her knee which was tender to the touch. The area was reported to hospice services and the Director of Nursing (DON). The son was notified of the right leg lump and was told she bumped her leg on the hoyer lift when going back to bed on Friday (05/12/23) night. Review of Resident #44's Witness Statement Form dated 05/21/23 authored by LPN #833 revealed on 05/15/23 she had received in report from the night nurse (RN #881) at approximately 5:50 A.M. that Resident #44 had a bump on her right leg. The form stated RN #881 reported Resident #44 bumped it on the Hoyer mechanical lift when the staff put her to bed and that she gave her a dose of morphine for pain. The area was assessed on her right inner calf below knee and the DON, physician and hospice were notified. X-rays were done to the area which was raised and tender with palpation. The son was made aware. Interview on 06/14/23 at 9:52 A.M. with LPN #833 indicated she worked dayshift on 05/15/23 and had observed a large lump on Resident #44's right lower leg with bruising. She stated she got in report from the nightshift nurse that the resident had bumped her leg on a Hoyer mechanical lift during a transfer. She could not remember the name of the nightshift nurse who gave her the report. 366434 Page 5 of 7 366434 06/16/2023 Hudson Springs Nursing and Rehab 5000 Sowul Boulevard Stow, OH 44224

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 06/14/23 at 9:58 A.M. with LPN #833 of Resident #44's right lower leg revealed an egg sized lump on her inner right mid leg with yellow, green and purple bruising on the top, side and back of her leg. The resident was not interviewable. Interview on 06/14/23 at 2:21 P.M. with the Administrator confirmed the injury investigation witness statements did not reflect evidence that Resident #44 actually bumped her leg on a Hoyer mechanical lift on 05/13/23 during a transfer and the investigation did not accurately determine the cause of resident #73's injury. He confirmed the dayshift nurse on 05/15/23 had documented that she received in report the resident had bumped her leg and morphine was administered for the pain. He also confirmed Resident #44 was not ordered morphine for pain. Review of the undated Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation policy indicated the facility would not tolerate abuse, neglect, misappropriation of resident property or exploitation of its residents. It would investigate all allegations, suspicion and incidents of abuse, neglect, misappropriation of resident property and exposition as well as injuries sustained by its residents. In addition such persons may file a grievance with the grievance official or with the State concerning any instance or suspicion of resident abuse. This deficiency represents non-compliance investigated under Complaint Number OH00143399. 366434 Page 6 of 7 366434 06/16/2023 Hudson Springs Nursing and Rehab 5000 Sowul Boulevard Stow, OH 44224

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 record review and interview, the facility failed to ensure Resident #73 received medications as ordered. This finding affected one (Resident #73) of four residents reviewed for medication administration. Findings include: Review of Resident #73's medical record revealed she was admitted on [DATE] and expired on [DATE] with diagnoses including encounter for other orthopedic aftercare, presence of left artificial knee joint and anxiety disorder. Review of Resident #73's Minimum Data Assessment (MDS) 3.0 assessment dated [DATE] revealed she exhibited intact cognition. Review of Resident #73's Clinical admission Documentation dated [DATE] at 2:35 P.M. revealed she arrived via a wheelchair with transportation services. Vital signs were obtained and she was in bed with the call light in reach. Review of Resident #73's physician orders revealed an order dated [DATE] for Eliquis (blood thinner) 2.5 mg twice a day and an order dated [DATE] for Entresto (used to treat chronic heart failure) 97-103 mg twice a day. Review of Resident #73's medication administration records (MARS) and treatment administration records (TARS) from [DATE] to [DATE] revealed she did not receive her Eliquis blood thinner on [DATE] from 7:00 P.M. to 11:00 P.M. Resident #73 also did not receive her Entresto heart medications on [DATE] from 7:00 P.M. to 11:00 P.M., [DATE] from 7:00 A.M. to 11:00 A.M. and on [DATE] from 7:00 P.M. to 11:00 P.M. Interview on [DATE] at 2:44 P.M. with Registered Nurse (RN) Regional #884 confirmed the pharmacy did not ensure Resident #73's Entresto heart failure medication was available for resident use and the resident was not administered Entresto on [DATE] or [DATE]. Interview on [DATE] at 9:57 A.M. with Physician #885 stated Resident #73's missed medications, including one Eliquis blood thinner and three Entresto heart medications. This deficiency represents non-compliance investigated under Complaint Number OH00143277. 366434 Page 7 of 7