Hudson Grande

Based on record review, interview, call light audit review and policy review, the facility failed to respond to call lights in a timely manner. This affected two (Residents #17 and #78) of three residents reviewed for call light responses. The facility census was 82.

Findings include:

1. Review of the medical record for Resident #17 noted an admission date of 03/07/25. Diagnoses included paraplegia, unspecified, neuromuscular dysfunction of the bladder, and need for assistance with personal care. Resident#17 had intact cognition.

Review of the service plans dated 08/25/25 noted Resident #17 needed assistance with transferring in/out of the shower, bowel and bladder incontinence, and dressing.

Review of the facility Senior Living Comprehensive Resident Evaluation dated 08/25/25 noted Resident #17 required assistance with dressing, incontinence care, and care while in bed.

Interview on 02/02/26 at 11:49 A.M., Resident #17 stated she must wait longer than 20 minutes most of the time for her call light to be answered. Resident #17 stated she is paralyzed and is dependent for incontinence care and transfers.

Review of call light audits for Resident #17 from 01/26/26 through 02/02/26 noted Resident #17 had to wait 55 minutes on 01/26/26 at 8:05 A.M., 65 minutes on 01/26/26 at 9:32 P.M., 32 minutes on 01/27/26 at 1:37 P.M., 76 minutes on 01/27/26 at 9:57 P.M., 30 minutes on 01/29/26 at 11:25 A.M., 56 minutes on 01/30/26 at 4:20 P.M., 42 minutes on 01/31/26 at 9:24 P.M., and 58 minutes on 02/02/26 at 10:19 A.M.

2. Review of the medical record for Resident #78 noted an admission date of 01/24/23. Diagnoses included muscle wasting and atrophy and unspecified severe protein-calorie malnutrition. Resident#78 had intact cognition.

Review of the service plan dated 10/07/24 noted Resident #78 required complete assistance with toileting and incontinence care.

Review of the facility Senior Living Comprehensive Resident Evaluation dated 01/27/26 noted Resident #78 required assistance with dressing and incontinence care.

Interview on 02/02/26 at 11:57 A.M., Resident #78 stated she must wait longer than 20 minutes most of the time for her call light to be answered. Resident #78 stated she had soiled herself several times waiting for staff to assist to the bathroom.

Review of call light audits for Resident #78 from 01/26/26 through 02/02/26 noted Resident #78 had to wait 80 minutes on 01/26/26 at 4:59 P.M., 48 minutes on 01/30/26 at 9:33 A.M., 28 minutes on 01/31/26 at 2:54 P.M., 65 minutes on 01/31/26 at 10:30 P.M., 58 minutes on 02/01/26 at 11:49 A.M., and 46 minutes on 02/02/26 at 5:50 A.M.

Interview on 02/02/26 at 2:04 P.M., the Executive Director and Wellness Director stated the expectation for staff to answer call lights is within 15 minutes. Both staff verified the long wait times and stated they were aware and added that concern to their business plan for 2026. The facility did not provide a policy related to call light response times and expectations of staff.

This violation represents non-compliance investigated under Complaint Number OH00169000.

Based on observation, interview, and record review, the facility failed to meet the needs of the residents when they failed to provide safe transfer of residents requiring assistance of a mechanical lift. This affected one (#22) of one resident reviewed for use of mechanical lift. The facility census was 80.

Findings include:

On 10/16/25 at 11:35 A.M., an observation of mechanical lift using a Hoyer revealed incorrect use of the Hoyer. Care Partner (CP) #113 and CP #137 were transferring Resident #22 from her bed to her wheelchair. While securing the resident to the hoyer with the lift pad and preparing to raise the resident into the air, CP #137 failed to set the brake on the hoyer lift. CP #137 confirmed she did not set the brake at the time of the observation.

On 10/16/25 at 11:50 A.M., an interview with CP #137 revealed when transferring a resident using a Hoyer, the CP should position the Hoyer at the proper position beside the resident's bed. The brakes of the Hoyer should be locked before any further contact with the resident occurred in order to keep the Hoyer from moving during the transfer to prevent resident injury.

Review of a facility policy titled Mechanical Lifts, dated 05/13/23, revealed the policy was to ensure the safety of the resident and the care partner. The policy indicated it was the responsibility of the employee to demonstrate proper techniques of the mechanical lifting device during performance of resident handling tasks.

Based on observation and record review, the facility failed to keep veterinary records for all pets in the facility to protect the health and wellness of all residents and staff members. This affected one (#53) of three residents pets reviewed. The facility census was 80.

Findings include:

On 10/16/25, review of facility pet records revealed there were no veterinary records on file for one facility pet. Resident #53 had a dog at the facility and the facility did not have any veterinary records for this pet. This was confirmed by the Wellness Director on 10/16/25 at 2:55 P.M.

Review of an undated facility policy titled Addendum: Pet Policy and Care Agreement revealed residents were required to provide an annual wellness exam by the veterinarian of tenant's preference. The pet had to be up to date on Bordatella, Rabies, and DHPP vaccinations. The pets also had to be on year-round flea and heartworm medications. Proof of vaccinations, annual exams and flea and heartworm medications were required and were to be given to the Executive Director to be kept on file.

Based on observation and staff interview the facility failed to implement measures to prevent food spoilage. This affected 80 residents. The facility census was 80.

Findings include:

Observation on 10/16/25 between 9:00 A.M. and 9:25 A.M. during the initial kitchen tour revealed the following:

A plastic scoop in the flour bin and a plastic scoop in the panko crumb bin.

Further observation revealed a single door refrigerator near the cooking station with one bottle of orange salad dressing with an expiration label of 10/13/25, one bottle of unidentified/unlabeled sauce, one opened container of egg salad with lid on and no open date noted and an expiration date of 10/11/25, one open container of chicken salad with lid on and no open date noted and an expiration date of 10/16/25, one block of American Cheese slices wrapped in plastic wrap with no label or dating, two croissants wrapped in plastic wrap with no label or date, one open large bag of green beans with no label for open date or expiration date, raw hamburger patties in a silver metal container not covered with lid or plastic covering, one bag of chicken tenders open with no dates or labels.

Further observation of the walk in cooler revealed a clear plastic container with a red lid unlabeled/undated with what appeared to be cubes of pepper jack cheese. There was a metal container with plastic covering with label reading Port Wine use by 10/13/25.

Further observation of the walk in freezer revealed a metal container unlabeled/undated with brown frozen contents. Observation revealed a container labeled stuffed peppers made on 09/10/25 and use by 09/17/25, there was not a date when the peppers were placed in the freezer. Continued observation revealed a bag of frozen corn open to air with no label indicating date open and expiration.

Interview on 10/16/25 at 9:03 A.M. with Dietary Server #170, revealed confirmation of scoops present in both flour and panko bins.

Interview on 10/16/25 at 9:10 A.M. with Sous Chef #181, revealed confirmation of contents in single refrigerator not labeled/date and expired items present. Sous Chef #181 removed all food items that were not dated or expired.

Interview on 10/16/25 at 9:15 A.M. with Dining Room Manager #154, revealed confirmation of unlabeled or expired items in both walk in freezer and walk in cooler.

Based on observation, staff interview, and review of the manufacturer's user manual and review of the Ohio Uniform Food Code, the facility failed to maintain sanitation of dishes and utensils used for meal service. This affected 80 residents. The facility census was 80.

Findings include:

Observation on 10/16/25 at 11:35 A.M. of the facility mechanical dishwasher revealed a load of dishes being washed with a wash temperature of 154-156 degrees Fahrenheit (F) and a rinse temperature of 153 degrees F. Further observation revealed a second load of dishes being washed with an internal digital thermometer used with wash and rinse temperature maximum of 163 degrees F and a low of 153 degrees F. Observation continued to reveal that a Rinse Aide and Detergent were the only chemicals being utilized with the mechanical dishwasher and there was no chemical sanitizer being utilized.

Interview on 10/16/25 at 11:35 A.M. with the Culinary Director (CD) #120 revealed confirmation of the temperature readings on both the outside of the machine and with the use of internal thermometer. The CD #120 reported the mechanical dishwasher was a high temperature dishwasher used for sanitation and did not have a chemical sanitizer being used in it. CD #120 reported the staff had only been checking water temperatures of the mechanical dishwasher using the internal digital thermometer and did not have logs of chemical sanitation testing since it was being used as a high water temperature sanitation washer. CD #120 reported he would notify the maintenance team to investigate the concern.

Review of the Hobart Operation Manual for dishwasher models AM15VL, AM15VLF, and AM15VLT found on page 23 revealed operating temperatures for all models as follows: for hot water sanitizing mode minimum wash temperature of 150 degrees F and minimum rinse temperature of 180 degrees F. Chemical sanitizing mode minimum wash temperature should be 120 degrees F with recommendation of 140 degrees F and recommended rinse temperature of 120 degrees F with recommendation of 140 degrees F.

Review of the Ohio Uniform Food Code 3717-1-04.4 J (1-2) revealed the temperature of the wash solution in spray type warewashers that use hot water to sanitize is not permitted to be less than:

(a) For a stationary rack, single temperature machine, one hundred sixty-five degrees Fahrenheit (seventy-four degrees Celsius);

(b) For a stationary rack, dual temperature machine, one hundred fifty degrees Fahrenheit (sixty-six degrees Celsius);

(c) For a single tank, conveyor, dual temperature machine, one hundred sixty degrees Fahrenheit (seventy-one degrees Celsius); or

(d) For a multitank, conveyor, multitemperature machine, one hundred fifty degrees Fahrenheit (sixty-six degrees Celsius).

Further review of the Ohio Uniform Food Code revealed mechanical warewashing equipment - hot water sanitization temperatures.

(1) In a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold cannot be more than one hundred ninety-four degrees Fahrenheit (ninety degrees Celsius), or less than:

(a) For a stationary rack, single temperature machine, one hundred sixty-five degrees Fahrenheit (seventy-four degrees Celsius); or

(b) For all other machines, one hundred eighty degrees Fahrenheit (eighty-two degrees Celsius).

Based on record review and interview, the facility failed to provide one quarterly fire drill on each shift. Further, the facility failed to evacuate residents in at least two of the three quarterly fire drills on each shift. This had the potential to affect all residents of the facility. The facility census was 80.

Findings include:

On 10/16/25, a review of facility fire drills reviewed the facility did not evacuate residents in two out of three quarterly fire drills on each shift. Dayshift fire drills were held on 12/24/24, 01/28/25, 04/29/25, and 07/30/25. No residents were noted as evacuated. Afternoon shift fire drills were held on 10/30/24, 02/27/25, and 05/29/25. No residents were noted as evacuated. Night shift fire drills were held on 11/27/24, 03/26/25, 06/18/25, and 08/19/25. No residents were noted as evacuated during any fire drill.

On 10/16/25, a review of facility fire drills reviewed the facility did not hold a fire drill on each shift quarterly. Dayshift fire drills were held on 12/24/24, 01/28/25, 04/29/25, and 07/30/25. Afternoon shift fire drills were held on 10/30/24, 02/27/25, and 05/29/25. To meet the quarterly requirement, a fire drill was due in January and August of 2025 on afternoon shift. There was no evidence of fire drills on afternoon shift in January 2025 or August 2025.

Night shift fire drills were held on 11/27/24, 03/26/25, 06/18/25, and 08/19/25. To meet the quarterly requirement, a fire drill was due in February 2025. There was no evidence of fire drills on night shift in February of 2025.

On 10/16/25 at 3:10 P.M., an interview with the Executive Director revealed the residents had not been evacuated in fire drills. She also confirmed the facility did not meet the quarterly fire drill on each shift requirement, based on reviews of the fire drills. She indicated they would be getting evacuation plans in place as soon as possible. The maintenance director who usually handled fire drills was out of the facility for an extended medical leave.

Review of an undated facility policy titled Fire Policy: General Information revealed the order for total evacuation was the responsibility of the person in charge of the facility or officer of the fire department. The staff was never to evacuate an entire area until told to do so by the person in charge, unless the residents were in immediate danger of fire. This policy was confirmed by the Executive Director on 10/16/25 at 3:10 P.M.

Based on observation and interview, the facility failed to maintain carpets in a manner to prevent accident or injury to residents of the memory care unit. This had the potential to affect all residents of the memory care unit. The memory care unit census was 20. The facility census was 80.

Finding include:

On 10/16/25 at 9:38 A.M. an observation of the memory care unit television room revealed a rug which was framed into the floor in disrepair. The rug was visibly soiled with several stains. Trim pieces around the rug were missing. This left a groove in the flooring around the rug. This was confirmed during the observation by the Memory Care Director (MCD).

On 10/16/25 at 9:38 A.M., an interview with the MCD confirmed the carpeting in the television room of the memory care unit was stained and in disrepair. She confirmed the carpeting presented a fall risk to residents of the memory care unit.

Based on observation and interview, the facility failed to maintain locks on outside doors to allow residents safe egress into the courtyard. This affected one (#30) of one resident reviewed for safe operation of doors. This had the potential to affect all residents of the facility. The facility census was 80.

Findings include:

On 10/16/25 at 10:15 A.M., an observation of room C25 revealed a door that lead to the outside courtyard. When the knob of the locked door was turned, the door would not unlock. This was confirmed by the Executive Director on 10/16/25 at 10:25 A.M.

On 10/16/25 at 10:15 A.M., an interview with Resident #30 revealed his door which lead to the courtyard would not unlock. He reported he had to jiggle it really hard, and then twist and pull on it in order for the door to unlock. Once unlocked, he would have a hard time getting the door to stay shut.

Based on staff interview and review of employee records the facility failed to provide its employees with a copy of phone numbers and address for the local and state health entities, local department of aging, local human services agencies, and the state Ombudsman office. This had the potential to affect 80 Residents. The facility census was 80.

Findings include:

Review of employee personnel files for employees #117, #124, #137 and #138 revealed no written acknowledgement of employees receiving a copy of the phone numbers and addresses for state and local health boards, local departments of aging, the state Ombudsman office, and state and county Human Services departments.

Interview on 10/16/25 at 12:45 P.M. with the Business Office Director #146 revealed confirmation that the staff did not have acknowledgements of receiving the required phone numbers and addresses of state and local agencies nor could she find any record of it being reviewed in staff meetings over the past twelve months. The Business Office Director #146 did confirm this information is provided to the Residents when they move in and the Ombudsman and other Resident advocates are posted near the front desk for Residents to easily access.

Based on record review and interview, the facility failed to ensure Resident #70 was transferred safely and her medical record was consistent in identifying the level of assistance required. This affected one (Resident #70) of three residents reviewed for personal care services. The census was 92.

Findings include:

Review of the medial record for Resident #70 revealed an admission date of 01/24/2023. Diagnoses included muscle wasting and atrophy left lower leg, venous insufficiency, hypertension and severe protein-calorie malnutrition. She was cognitively intact.

Review of a progress note dated 03/03/24 revealed Resident #70 was a two-person assist with mechanical lift.

Review of a therapy note dated 8/28/24 revealed Resident #70 was advanced to a walker for transfers to and from her bed.

Review of the monthly wellness note dated 09/05/24 revealed Resident #70 had mechanical lift and other equipment in place.

Review of Resident #70's Order Note dated 09/12/24 revealed the resident refused therapy on this date. Nursing was notified of refusal due to left shoulder pain. Upon assessment, left shoulder noted to have prominence of unknown origin. The resident described the pain of a level three out of ten and stated the she had pain with movement. No swelling or bruising was noted. The certified nurse practitioner was noted and an order for an X-ray of left shoulder was received.

Review of Resident #70's Wellness Note dated 09/12/24 revealed the X-ray results showed no evidence of dislocation, fracture, or acute disease. There was evidence of degenerate bone disease.

Review of the orders for October 2024 revealed an order for a mechanical lift since 09/2023.

Review of the Service Plan for October 2024 revealed Resident #70 would be assisted for transfers but did not specify how or with what equipment.

Review of the electronic task sheet dated 10/04/2024 for Resident #70 revealed she required a two-person assist with mechanical lift for transfers.

Interviews on 10/04/24 from 10:10 A.M. to 1:30 P.M. with Care Partners (CP) and Licensed Practical Nurse revealed staff received verbal report on how a resident transfers or they look at the service plan or electronic task sheet.

Interview on 10/04/24/at 11:30 A.M. with Resident #70 revealed on 09/11/24 CP #201 transferred her to the toilet without using a gait belt despite her asking her to use it. Resident #70 revealed the CP explained they knew what they were doing but proceeded to transfer her without a gait belt. Resident #70 revealed she heard a pop in her shoulder and she screamed. She revealed she complained of pain in her shoulder to a nurse who ordered and X-ray.

Interview on 10/04/24 at 12:20 P.M. with Resident #70's family member confirmed Resident #70 reported the above events to him. Family member revealed the resident's shoulder had been hurting her for a long time prior to this incident but there was never a protrusion.

Interview on 10/04/24 at 1:27 P.M. with CP #201 revealed she may not have use a gait belt with Resident #70.

Interview on 10/04/24 at 1:38 P.M. with CP #207 revealed she was in the room when CP #201 transferred Resident #70 stating CP #201 did not use a gait belt.

Interview on 10/04/24 at 2:15 P.M. with Assistant Wellness Director (AWD) revealed nurse management got a weekly report from the therapist with current information on transfers. Staff could look at the service plan or electronic task sheet for updates. AWD stated they left the mechanical lift in Resident #70's room in case she needed it therefore they left it in the orders and service plan. She verified Resident #70's electronic task sheet, orders and service plan were not up to date. She concluded CP #201 did not use any equipment (neither mechanical lift nor gait belt) with Resident #70 therefore did not follow the service plan but also verified the transfer status was not up to date in the record.

This violation represents non-compliance investigated under Complaint Number OH00157885.

Based on record review and interview, the facility failed to ensure Residents #20, #50, #54 and #84 were assessed upon admission to determine if the resident was capable to self-administer medications. This finding affected four (Residents #20, #50, #54 and #84) of five residents reviewed for comprehensive assessments.

Findings include:

1. Review of Resident #20's medical record revealed the resident was admitted on 11/08/23 with diagnoses including essential hypertension and malignant neoplasm of the breast.

Review of Resident #20's Mental Status Questionnaire form dated 12/14/23 revealed the resident exhibited mild or no cognitive impairment.

Review of Resident #20's History and Physical (H&P) form dated 11/08/23 and the resident's medical record did not have evidence the resident was assessed to determine if the resident was capable of self-administering medications.

Interview on 07/03/24 at 2:50 P.M. with the Director of Nursing (DON) confirmed Resident #20's self-administration assessment was not completed as required.

2. Review of Resident #50's medical record revealed the resident was admitted on 11/17/23 with diagnoses including cerebral infarction, essential hypertension and benign prostatic hyperplasia.

Review of Resident #50's Mental Status Questionnaire form dated 04/26/24 revealed the resident had severe cognitive impairment.

Review of Resident #50's H&P form dated 11/15/23 and the facility's medical record did not have evidence the resident was assessed to determine if the resident was capable of self-administering medications.

Interview on 07/03/24 at 2:50 P.M. with the DON confirmed Resident #50's self-administration assessment was not completed as required.

3. Review of Resident #54's medical record revealed the resident was admitted on 07/27/23 with diagnoses including overactive bladder, diabetes and muscle weakness.

Review of Resident #54's Mental Status Questionnaire form dated 01/19/24 revealed the resident had mild or no cognitive impairment.

Review of Resident #54's H&P form dated 07/20/23 as well as the resident's medical record did not have evidence the resident was assessed to determine if the resident was capable of self-administering medications.

Interview on 07/03/24 at 2:50 P.M. with the DON confirmed Resident #54's self-administration assessment was not completed as required.

4. Review of Resident #84's medical record revealed the resident was admitted on 10/25/23 with diagnoses including essential hypertension and altered mental status.

Review of Resident #84's Mental Status Questionnaire form dated 05/04/24 revealed the resident exhibited mild or no cognitive impairment.

Review of Resident #84's H&P form dated 10/16/23 and the resident's medical record did not have evidence the resident was assessed to determine if the resident was capable of self-administering medications.

Interview on 07/03/24 at 2:50 P.M. with the DON confirmed Resident #84's self-administration assessment was not completed as required.

Based on record review and interview, the facility failed to ensure Resident #91 was assessed annually to determine if the resident was capable to self-administer medications. This finding affected one (Resident #91) of five residents reviewed for comprehensive assessments.

Findings include:

Review of Resident #91 medical record revealed the resident was admitted on 03/17/23 with diagnoses including unspecified macular degeneration, essential hypertension and chronic metabolic acidosis.

Review of Resident #91's Mental Status Questionnaire form dated 03/14/24 revealed the resident exhibited mild or no cognitive impairment.

Review of Resident #91's history and physical form dated 3/11/23 and the resident's medical record did not reveal evidence a self-administration evaluation was completed annually to determine if the resident was capable of self-administering medications.

Interview on 07/03/24 at 2:50 P.M. with the Director of Nursing (DON) confirmed Resident #91's self-administration assessment was not completed as required.

Based on observation and interview, the facility failed to ensure hair coverings were implemented to prevent possible cross-contamination of resident food. This finding has the potential to affect all 84 residents residing in the facility.

Findings include:

1. Observation on 07/03/24 at 8:34 A.M. revealed Server #701 was in the servery of the secured memory care unit (SMCU) plating food for the residents. Server #701 was observed putting on the hairnet to secure her hair in order to prevent possible food contamination approximately half-way through breakfast.

Interview on 07/03/24 at 8:38 A.M. with Server #701 confirmed she did not have a hair net in place to secure her hair to prevent possible cross contamination of the breakfast meal.

2. Observation on 07/03/24 at 11:07 A.M. revealed Sous Chef #702 was fixing an egg and cheese sandwich in the main portion of the kitchen for a resident. Sous Chef #702 had a black hat in place with hair hanging on the back of his neck and collar and he had a full beard and mustache. The hair on the back of his neck and collar as well as the beard and moustache were not contained.

Interview on 07/03/24 at 11:10 A.M. with Sous Chef #702 confirmed he did not use a hair net underneath of his hat to secure his hair or implement a beard guard to prevent potential cross contamination of the resident's meals during cooking.

Based on record review and interview, the facility failed to ensure residents capable of self-evacuation were actually evacuated in two of four fire drills per year per shift. This finding had the potential all 84 residents who reside in the facility.

Findings include:

Review of the fire drills from 07/07/23 to 06/15/24 with Plant Operations Manager #801 revealed no residents were evacuated during the fire drills.

Interview on 07/03/24 at 9:06 A.M. with Plant Operations Manager #801 confirmed the facility did not have evidence residents capable of self-evacuation were actually evacuated in all twelve fire drills from 07/07/23 to 06/15/24.