Inspection·December 28, 2023

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of medscape, the facility failed to ensure residents were not prescribed unnecessary antibiotic medications. This affected one (Resident #12) out of five residents reviewed for unnecessary medications. The current census is 44. Residents Affected - Few Findings include: Record review for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #12 include Alzheimer's, dementia with behaviors, chronic kidney disease, and schizophrenia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was receiving antibiotics. Per the assessment the resident had not been diagnosed with a urinary tract infection in the past 30 days. Review of Resident #12's care plans dated 12/27/21 revealed the resident was at for risk of chronic urinary tract infections. Interventions include administer medication per order, monitor for signs and symptoms of infections, avoid irritants, avoid tight pants, and assist with incontinence. Review of Resident #12's physician orders revealed on 04/25/23 the resident was ordered to receive Macrodantin oral antibiotic 50 milligrams (mg) 1 capsule daily for prophylaxis of urinary tract infections (UTI). Per the orders the Macrodantin antibiotic was re-ordered on 11/07/23 to continue for prophylaxis antibiotics for UTI. Review of Resident #12's Medication Administration Record (MAR) dated from 01/2022 to 11/2023 revealed the resident had received the oral antibiotic per physician order. Review of Resident #12's urinalysis and culture and sensitivity tests dated 11/11/22 and 09/16/23 revealed the resident's urine did not contain bacteria causing urinary tract infections. Interview on 12/28/23 at 11:00 A.M. with the Infection Control Prevention nurse (ICP) Licensed Practical Nurse (LPN) #87, verified Resident #12 did not have any signs or symptoms of a urinary tract infection which would require an antibiotic treatment. LPN #87 verified the facility's medical director continued to prescribe the oral antibiotic for Resident #12 against the facility followed antibiotic stewardship protocols. Per the LPN #87, the medical director had stated Resident #12 will continue to receive the antibiotic in order to prevent future UTIs. Interview on 12/28/23 at 1:52 P.M. with the Medical Director revealed the physician prescribed the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365505 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 365505 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Green Rehabilitation and Healthcare Center 1315 Kitchen Aid Way Greenville, OH 45331 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)