Health inspection·February 18, 2025

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 medical record review, staff interview, and policy review, the facility failed to follow physician orders for weekly weights and medication administration. This affected three residents (#36, #16, and #2) of eight residents reviewed for following physician orders. The census was 43. Residents Affected - Few Findings included: 1. Medical record review for Resident #36 revealed an admission date of 08/23/22. Medical diagnoses included cerebrovascular attack (CVA), dementia, and aphasic. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #36 was moderately cognitively impaired. Review of the physician orders dated 06/07/24 revealed to obtain weekly weights for Resident #36. Review of the care plan dated 06/07/24 revealed Resident #36 was at risk for weight loss and an intervention was for weekly weights. Review of the weights since 11/27/24 for Resident #36 revealed there were missing weights for 11/27/24, 12/11/24, 12/18/24, 12/28/24, 01/04/25, 01/18/25, and 01/28/25. Interview with the Registered Dietician (RD) #205 on 02/18/25 at 2:19 P.M. confirmed Resident #36 missed some weights. She stated at one point the weight order dropped off due to hospitalization and she had to enter the order again into the system. 2. Medical record review for Resident #16 revealed an admission date of 07/26/24. Medical diagnoses included diabetes, renal insufficiency, and dementia. Review of the quarterly MDS dated [DATE] revealed Resident #16 was cognitively intact. Review of the physician orders dated 12/08/24 for Resident #16 revealed to weigh the resident weekly. Review of weights since 12/08/24 for Resident #16 revealed weights for 12/18/24, 01/28/25, and 02/11/25 were missing. Review of the care plan for Resident #16 dated 01/31/25 revealed she was at risk for weight loss. Page 1 of 4 365812 365812 02/18/2025 Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215

F 0684 Level of Harm - Minimal harm or potential for actual harm Interview with the RD #205 on 02/18/25 at 2:19 P.M. confirmed there were missing weights for Resident #16. 3. Medical record review for Resident #23 revealed an admission date of 07/29/24. His diagnoses included heart failure, renal insufficiency and diabetes. Residents Affected - Few Review of physician orders dated 10/21/24 revealed Resident #23 was to be weighed weekly. Review of the quarterly MDS dated [DATE] revealed Resident #23 was cognitively intact. Review of care plan dated 02/18/25 revealed Resident #23 was at risk for weight loss related to dialysis. Review of the weekly weights since 12/28/24 revealed the weights were not taken on 12/28/24, 01/04/25, 01/28/25 and 02/04/25. Interview with the RD #205 confirmed the weights have not been done weekly. There are times of refusal for him, but they were not documented. This deficiency represents non-compliance investigated under Complaint Number OH00160894. 365812 Page 2 of 4 365812 02/18/2025 Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215

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 observation, medical record review, and staff interview, the facility failed to administer medications as ordered. This affected one (Resident #32) of three residents observed for medication administration. The facility census was 43. Findings include: Medical record review for Resident #32 revealed an admission date of 12/05/24. Medical diagnosis included Alzheimer's disease. Review of the admission MDS dated [DATE] revealed Resident #32 was moderately cognitively impaired. Review of physician orders dated 12/05/24 revealed Folic Acid Oral Tablet one milligram (mg) to give one mg by mouth one time a day for dietary supplement During medication observation with agency Licensed Practical Nurse (LPN) #210 on 02/18/25 at 8:50 A.M. revealed she took a Folic Acid 880 micrograms (mcg) medication out of the bottle and placed in the medication cup. Interview with the LPN #210 on 02/18/25 at 8:52 A.M. revealed she didn't work at the facility. She said the closet medication to the one mg of Folic Acid was the 880 mcg's and the only other option was to not give it to the resident. She stated she didn't know why the pharmacy didn't send the right medication. She confirmed she was going to give the 880 mcg's and not do anything else about the medication. Review of the policy entitled, Medication Administration dated 02/23/24 revealed medications shall be administered in accordance with the physician/ authorized practitioner orders. This deficiency represents non-compliance investigated under Complaint Number OH00160894. 365812 Page 3 of 4 365812 02/18/2025 Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, and policy review, the facility failed to ensure medications for administration was not pre-poured prior to administration. This affected eight residents (#2, #3, #4, #5, #6, #18, #19, and #20) of thirteen residents who resided on the 200 hall reviewed for medication administration. The census was 43. Findings includes: Observation on 02/18/25 at 7:43 A.M. revealed the inside of the medication cart Licensed Practical Nurse (LPN) #200 was using revealed medication cups pre-filled with Resident's #2, #3, #4, #5, #6, #18, #19, and #20 medications for the morning doses. Interview with the LPN #200 on 02/18/25 at 7:45 A.M. revealed she was an agency nurse and confirmed she pre-poured the medications for above mentioned residents. She said she wasn't sure if she could do this at this facility, but has done it at other facilities. Review of policy entitled, Medication Administration, dated 02/23/24 revealed medications may not be prepared in advance. 365812 Page 4 of 4