Hudson Springs Nursing And Rehab

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based on review of video camera footage, interviews with staff and a police detective, and record review, the facility failed to implement the comprehensive, person-centered care plan for Resident #2.

This affected one (#2) of three residents reviewed for care plans.

The facility census was 69.

Findings include: Review of the medical record for Resident #2 revealed an admission date 01/24/25.

Diagnoses included Parkinson's disease, wedge compression fracture of third lumbar vertebra, chronic respiratory failure, severe osteoporosis, dementia, tracheostomy, and above the knee amputee.

Review of the care plan revealed Resident #2 had a self-care performance deficit related to disease process Parkinson's disease, impaired balance, limited mobility and impaired range of motion due to bilateral hand/wrist contractures.

Interventions included Resident #2 required two staff assistance for repositioning, dressing, personal hygiene/oral care and toileting. A video provided on 10/22/25 at 12:34 P.M. by Detective #850 revealed on 09/15/25 at 11:30 A.M., two staff members came into Resident #2's room to provide incontinence care.

One staff member walked away and the other staff member repositioned resident one assist. On 09/21/25 at 10:53 A.M. one staff member repositioned Resident #2. At 4:08 P.M. one staff member started preforming incontinence care.

Interview on 10/22/25 at 10:20 A.M. with Registered Nurse (RN) #803 revealed Resident #2 was a two-persons assist for incontinence care and repositioning.

Interview on 10/22/25 at 11:30 A.M. with Certified Nursing Assistant (CNA) #819 and #820 verified Resident #2 was two-persons assistance for incontinence care and repositioning.

Interview on 10/22/25 at 12:13 P.M. with Detective #850 stated she received a complaint from Resident #2's daughter and was provided with videos of Resident #2 being repositioned and incontinence care with one assist and Resident #2 was a two-persons assistance for incontinence care and repositioning.

Detective #850 verified he spoke with the Administrator on 10/16/25 of the allegations.

Detective #850 stated she would email her report and documents that were given to her.

She stated Resident #2's daughter would not give consent to review Resident #2's medical records.

Interview on 10/22/25 at 2:21 P.M. with the Administrator and Director of Nursing (DON) verified Resident #2 was a two-persons assist for all transfers, repositioning and incontinence care.

The Administrator verified she was contacted by Detective #850 and was told she was looking into a complaint. At this time, the Administrator and DON were notified that the surveyor had received videos that showed Resident #2 was being repositioned and being provided with incontinence care of one staff assist. At that time, the DON verified Resident #2 was a two-persons assistant with incontinent care and repositioning.

This deficiency represents non-compliance investigated under Complaint Number 2649075.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/23/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Hudson Springs Nursing and Rehab

5000 Sowul Boulevard Stow, OH 44224

SUMMARY STATEMENT OF DEFICIENCIES

Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact and was dependent on staff for toileting hygiene, was always incontinent of bowel, and had a indwelling catheter.

Review of Resident #25's care plan revealed she had deficit in self-care performance related to morbid obesity and pulmonary disease.

Interventions included Resident #25 was totally dependent on two staff for toilet use and bed mobility. Resident #25's care plan revealed she had impaired skin integrity to right lateral thigh due to bedfast and impaired mobility.

Interventions included to check and change approximately every two-to-three hours and as needed related to incontinence, assist with hygiene and general skin care, and keep skin clean and dry.

Interview with Resident #25 on 10/20/25 at 9:55 A.M. revealed she has been waiting to be cleaned up after having a bowel movement earlier in the morning. Resident #25 stated she has not been checked and changed since night shift left. Resident #25 stated she put her call light on around 8:00 A.M. and when Certified Nursing Assistant (CNA) #819 came into her room, CNA #819 told Resident #25 she would be right back in a few.

CNA #819 turned off the call light. Resident #25's linens were visibly soiled with an extra-large bowel movement.

Observation on 10/20/25 at 11:12 A.M. revealed CNAs #819 and #820 were going to provide Resident #25 with incontinence care for the first time on their shift. Resident #25 did not wear a depends due to irritates her skin. Resident #25 required a full bed linen change and complete perineal cleansing due to the extent of the soiling. Resident #25 had an extra-large bowel movement (BM) down her thighs, in her skin creases and all around her catheter.

Interview on 10/20/25 at 12:15 P.M. with CNA #819 verified she had not changed Resident #25 since starting her shift at 7:00 A.M. and she knew earlier that Resident #25 had had a BM and needed changed. CNA #819 explained she had to assist other residents before she provided incontinence care to Resident #25.

This deficiency represents non-compliance investigated under Master Complaint Number 2649075 and Complaint Number 2642045.

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