Inspection Reports for Hudson Springs Nursing & Rehab
5000 Sowul Blvd, Stow, OH 44224, United States, OH, 44224
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
69 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 3
Date: Oct 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of insufficient linen availability, failure to implement care plans, and failure to provide timely assistance with activities of daily living, including incontinence care, for residents at Hudson Springs Nursing and Rehab.
Complaint Details
The complaint investigation was triggered by allegations related to insufficient linens, failure to follow care plans, and inadequate assistance with incontinence care. The investigation included interviews, observations, video footage review, and record review. The facility was found non-compliant under Complaint Numbers 2593016, 2649075, 2642045, and Master Complaint Number 2649075.
Findings
The facility failed to ensure sufficient linens were available for resident care, failed to implement the comprehensive care plan for Resident #2 requiring two-person assistance, and failed to provide timely incontinence care to Resident #25. Observations, interviews, and record reviews confirmed these deficiencies affecting residents' hygiene and care.
Deficiencies (3)
Failed to ensure sufficient linens were available for resident care and maintain a clean and sanitary environment affecting Resident #25.
Failed to implement the comprehensive, person-centered care plan for Resident #2 requiring two-person assistance.
Failed to provide timely assistance with activities of daily living, including incontinence care, for Resident #25.
Report Facts
Facility census: 69
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #819 | Certified Nursing Assistant | Named in findings related to linen shortages and delayed incontinence care for Resident #25 |
| CNA #820 | Certified Nursing Assistant | Named in findings related to incontinence care for Resident #25 |
| LPN #818 | Licensed Practical Nurse | Observed clean linen closet with no towels or washcloths |
| HLS #821 | Housekeeping/Laundry Supervisor | Verified lack of linen supplies and discussed linen hiding |
| RN #803 | Registered Nurse | Interviewed regarding Resident #2's care needs |
| Detective #850 | Police Detective | Provided video evidence and conducted complaint investigation |
| Administrator | Verified findings and facility linen search | |
| Director of Nursing | DON | Verified Resident #2's care requirements and acknowledged video evidence |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
The inspection was conducted due to a complaint or allegation regarding the facility's failure to provide safe and appropriate respiratory care for a resident when needed.
Complaint Details
The complaint investigation revealed that respiratory treatments were not administered as ordered on 01/17/25 at 6:00 P.M. for Resident #38. The respiratory therapist was uncomfortable performing the treatment and did not notify the physician until the following day. The Nurse Practitioner was updated on 01/18/25 at 7:00 A.M.
Findings
The facility failed to ensure respiratory treatments, including chest vest application and Albuterol Sulfate inhalation, were administered as ordered for Resident #38. The respiratory therapist did not perform the treatments due to discomfort with the procedure, and the physician or nurse practitioner was not promptly updated until the following day.
Deficiencies (1)
Failure to provide respiratory treatments (chest vest and Albuterol Sulfate) as ordered for Resident #38.
Report Facts
Residents reviewed for respiratory care: 3
Facility census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT #211 | Respiratory Therapist | Did not administer chest vest and Albuterol Sulfate as ordered due to discomfort and fear of dislodging tube sites |
| RT #210 | Respiratory Therapist | Educated RT #211 on how to utilize the chest vest on Resident #38 |
| NP #212 | Nurse Practitioner | Was updated on 01/18/25 at 7:00 A.M. about the missed respiratory treatments |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Date: Dec 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's food storage practices.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00159545.
Findings
The facility failed to store food in a sanitary manner, with multiple food items in the kitchen lacking proper labeling and dating, potentially affecting all residents except those ordered nothing by mouth.
Deficiencies (1)
Failure to store food in a sanitary manner with unlabeled and undated food items in the kitchen.
Report Facts
Census: 75
Food container dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager (DM) #1 | Interviewed during kitchen tour confirming food labeling and dating issues | |
| Administrator | Interviewed confirming all food should be labeled and dated |
Inspection Report
Routine
Census: 65
Deficiencies: 17
Date: Aug 21, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey of Hudson Springs Nursing and Rehab to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found to have multiple deficiencies including failure to promote resident self-determination, improper management of resident funds, untimely and inaccurate Minimum Data Set (MDS) submissions, incomplete care plans, inadequate assistance with activities of daily living, medication errors, failure to follow dietary and infection control policies, insufficient staffing, and failure to offer vaccinations.
Deficiencies (17)
Failed to ensure residents were not left in their rooms without visual or audio stimulation.
Failed to ensure residents with financial accounts received quarterly statements as required.
Failed to ensure appropriate beneficiary notices were provided timely at the end of Medicare services.
Failed to ensure Nurse Aide Registry checks were completed on employees upon hire.
Failed to ensure MDS assessments were submitted timely.
Failed to ensure MDS assessments were accurately completed.
Failed to ensure care plans were updated timely and care conferences were held.
Failed to ensure showers were provided as scheduled for dependent residents.
Failed to ensure intravenous dressings were changed per physician order and as needed.
Failed to ensure ongoing communication and collaboration with the dialysis center.
Failed to ensure residents with a history of trauma were appropriately assessed to identify triggers to minimize re-traumatization.
Failed to have sufficient staff to meet the acuity needs of each resident.
Failed to ensure non-pharmacological interventions were attempted prior to administration of PRN anti-anxiety medication and failed to document effectiveness or rationale for extended use.
Failed to ensure residents were free of significant medication errors.
Failed to ensure mechanically altered diet was prepared according to dietary spreadsheet and policy.
Failed to ensure appropriate personal protective equipment was donned prior to providing care to a resident on Enhanced Barrier Precautions and failed to implement contact precautions timely for a resident with a transmissible infection.
Failed to ensure influenza and pneumococcal vaccinations were offered to all residents.
Report Facts
Facility census: 65
Residents affected: 1
Residents affected: 5
Residents affected: 3
Residents affected: 65
Residents affected: 11
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 8
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #488 | Licensed Practical Nurse | Administered incorrect Depakote dose to Resident #28 |
| LPN #600 | Licensed Practical Nurse | Administered double dose of Percocet to Resident #17 |
| RN #601 | Registered Nurse | Reported medication error for Resident #17 |
| DON | Director of Nursing | Informed physician of medication error for Resident #28 and confirmed lack of documentation for PRN medication rationale |
| STNA #404 | State Tested Nursing Assistant | Interviewed regarding resident stimulation and trauma informed care |
| STNA #426 | State Tested Nursing Assistant | Reported discovery of pressure ulcer on Resident #40 |
| RN #407 | Registered Nurse Supervisor | Observed pressure ulcer and failed to notify physician timely |
| LPN #458 | Licensed Practical Nurse | Observed IV dressing issues and wound care for Resident #40 |
| ADM #419 | Assistant Dietary Manager | Confirmed dietary errors on mechanically altered diet |
| RD #481 | Registered Dietitian | Confirmed dietary errors on mechanically altered diet |
| DSW #496 | Dialysis Social Worker | Reported lack of communication from facility to dialysis center |
| RNS #405 | Registered Nurse Supervisor | Reported staffing shortages |
| STNA #424 | State Tested Nursing Assistant | Reported staffing shortages |
| STNA #440 | State Tested Nursing Assistant | Reported long call light wait times |
| LSW #429 | Licensed Social Worker | Responsible for care planning and trauma informed care |
| DM #444 | Dietary Manager | Confirmed dietary errors and food preference issues |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 3
Date: Aug 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to medication administration errors and infection control concerns at Hudson Springs Nursing and Rehab.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00144221 related to medication administration errors and under Master Complaint Number OH00145361 related to infection control screening failures.
Findings
The facility failed to ensure timely administration of medications to Resident #75, resulting in significant medication errors including missed seizure medications. Additionally, the facility failed to properly screen and monitor infections, specifically Carbapenem Resistant Acinetobacter Baumanii (CRAB), affecting Resident #47 and potentially others.
Deficiencies (3)
Failed to ensure medications were administered timely according to physician orders for Resident #75.
Failed to ensure Resident #75 was free from significant medication errors when seizure medications were not administered.
Failed to ensure proper screening and monitoring of infections to prevent development and transmission of CRAB, affecting Resident #47 and potentially all residents.
Report Facts
Facility census: 72
Residents reviewed for medication administration: 3
Residents reviewed for infection control: 4
Medication administration errors: 1
Residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #193 | Registered Nurse | Entered physician orders into the system and progress notes for Resident #75 |
| Director of Nursing | Director of Nursing (DON) | Contacted physician regarding missed medications and ordered infection screening |
| RN #192 | Registered Nurse | Did not administer Resident #75's medications on 06/28/23 due to unavailability |
| Regional Nurse Consultant #191 | Regional Nurse Consultant | Confirmed Resident #75 did not receive medications as ordered |
| Physician #194 | Physician | Provided physician orders and confirmed expectation for medication administration |
| Pharmacist #195 | Pharmacist | Reported on stock medications and pharmacy delivery process |
| LHD Registered Nurse #300 | Local Health Department Registered Nurse | Reported on CRAB infection and lack of screening by facility |
| Assistant Director of Nursing #186 | Assistant Director of Nursing (ADON) | Delegated infection screening responsibility but did not complete screening |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation focusing on allegations related to injury notification, medication administration, and injury assessment and investigation at Hudson Springs Nursing and Rehab.
Complaint Details
The complaint investigation revealed multiple deficiencies including failure to notify family and physician of injury, failure to obtain vital signs as ordered, failure to timely assess injury, failure to conduct thorough injury investigation, and failure to administer medications as ordered.
Findings
The facility failed to timely notify Resident #44's family and physician of an injury, failed to ensure Resident #73's vital signs were obtained per physician orders, failed to assess Resident #44's injury timely, failed to complete a thorough injury investigation for Resident #44, and failed to ensure Resident #73 received medications as ordered.
Deficiencies (4)
Failed to timely notify Resident #44's family and physician of an injury to the right lower leg.
Failed to ensure Resident #73's vital signs were obtained per physician's order and failed to ensure Resident #44's injury was assessed timely.
Failed to ensure timely and thorough investigation of Resident #44's injury to her right lower leg.
Failed to ensure Resident #73 received medications as ordered.
Report Facts
Residents reviewed for injuries: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Medication doses missed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #881 | Registered Nurse | Named in failure to document injury and notify physician and family for Resident #44 |
| LPN #833 | Licensed Practical Nurse | Authored notes and witness statements regarding Resident #44's injury |
| RN Regional #884 | Registered Nurse | Confirmed Resident #73's vital signs were not taken per physician orders and medication issues |
| Physician #885 | Physician | Commented on missed medications for Resident #73 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 5, 2023
Visit Reason
The inspection was conducted as a complaint investigation into allegations of misappropriation of narcotic medications and failure to provide timely incontinence care to residents.
Complaint Details
The complaint investigation found substantiated incidents of misappropriation of narcotic medications by Licensed Practical Nurse (LPN) #985, an agency nurse, involving Residents #9 and #19. Additionally, Resident #99 did not receive timely incontinence care on 04/15/23, with staff switching and failure to provide care overnight. The complaint number is OH00142198.
Findings
The facility failed to prevent misappropriation of narcotic pain medications by an agency nurse affecting two residents, and failed to provide timely incontinence care to one resident, resulting in minimal harm or potential for harm.
Deficiencies (2)
Failed to protect residents from wrongful use of their belongings or money, specifically misappropriation of narcotic pain medications by an agency nurse.
Failed to provide timely incontinence care to a resident, resulting in soiled linens and resident discomfort.
Report Facts
Tablets misappropriated: 30
Tablets misappropriated: 30
Suspension duration: 3
Date of incident: Apr 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #985 | LPN | Suspected of misappropriating narcotic medications |
| Registered Nurse Director of Nursing #987 | RN Director of Nursing | Provided statement regarding narcotic misappropriation incident |
| Registered Nurse #986 | RN | Confirmed suspicion of narcotic misappropriation by LPN #985 |
| State Tested Nursing Assistant #804 | STNA | Reported on incontinence care incident and staff switching |
| State Tested Nursing Assistant #805 | STNA | Assigned to Resident #99, suspended for failure to provide timely incontinence care |
| Agency STNA #806 | Agency STNA | Assigned to Resident #99 overnight, failed to provide incontinence care |
| State Tested Nursing Assistant #807 | STNA | Took picture of Resident #99's soiled bed linens and sent to family member |
| Administrator | Administrator | Educated staff involved in incontinence care incident and policy violations |
Inspection Report
Routine
Census: 59
Deficiencies: 1
Date: Apr 20, 2022
Visit Reason
The inspection was conducted to ensure compliance with medication storage policies, specifically verifying that drugs and biologicals were labeled and stored according to professional principles and manufacturer's guidelines.
Findings
The facility failed to ensure medications were appropriately labeled and dated once opened, affecting nine residents. Multiple medications on two medication carts and in the medication storage refrigerator were found without dates of opening or expiration dates as required by policy and manufacturer instructions.
Deficiencies (1)
Medications including insulin pens, ophthalmic solutions, ointments, gels, and inhalation aerosols were found opened without dates of opening or expiration dates as per manufacturer's guidelines.
Report Facts
Residents affected: 9
Facility census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #520 | Confirmed findings of unlabeled medications on medication carts and in medication storage refrigerator | |
| Registered Nurse (RN) #503 | Confirmed findings of unlabeled medications on medication carts |
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 4
Date: May 9, 2019
Visit Reason
The inspection was conducted as part of the annual survey and complaint investigation to assess compliance with care planning, medication administration, food service, infection control, and other regulatory requirements.
Complaint Details
The deficiency related to failure to administer Flonase nasal spray as ordered substantiates Complaint Number OH00103897 investigated concurrently with the annual survey.
Findings
The facility was found deficient in several areas including failure to develop complete, person-centered care plans addressing resident refusals; failure to administer medications as ordered; failure to ensure food was served at palatable temperatures; and failure to implement proper infection prevention and control practices, including improper storage of respiratory equipment and inadequate isolation precautions.
Deficiencies (4)
Failure to develop and implement a complete care plan that meets all the resident's needs, including addressing refusals of weights.
Failure to provide appropriate treatment and care according to orders, including failure to administer Flonase nasal spray as ordered.
Failure to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature.
Failure to provide and implement an infection prevention and control program, including failure to follow isolation precautions and improper storage of respiratory equipment.
Report Facts
Residents reviewed for care planning: 21
Residents affected by care plan deficiency: 1
Facility census: 69
Weight loss percentage: 14
Weight loss in pounds: 26
Days Flonase nasal spray not administered: 14
Food trays served: 300
Hot food temperature guideline: 135
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RRD #102 | Regional Registered Dietitian | Interviewed regarding weight refusals and food temperature testing |
| STNA #115 | State Tested Nurse Aide | Reported Resident #32 often refused weights and reattempted weighing |
| Director of Nursing | Director of Nursing (DON) | Verified care plan deficiencies and staff procedures for weight refusals |
| RN #109 | Registered Nurse | Observed administering medication and verified medication issues |
| Pharmacist #111 | Pharmacist | Interviewed about medication supply and administration |
| FSD #100 | Food Service Director | Interviewed about food temperature and meal service |
| STNA #128 | State Tested Nurse Aide | Observed failing to follow isolation precautions |
| LPN #108 | Licensed Practical Nurse | Verified improper storage of respiratory equipment |
| RN #107 | Registered Nurse | Verified improper storage of respiratory equipment |
| LPN #113 | Licensed Practical Nurse | Indicated respiratory equipment should be stored in plastic bags |
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