Health inspection·July 18, 2019

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on resident funds record review, medical record review, staff interview, and review of facility policy, the facility failed to notify the resident and/or responsible party when the trust fund account balance was within $200.000 of the Medicaid limit for two (#20 and #43) of five residents reviewed for funds managed by the facility. The facikity identified 26 residents with trust fund accounts. The facility census was 106. Residents Affected - Few Findings include: 1. Review of the medical record of Resident #20 revealed an admission date of 08/17/18. Diagnoses included dementia without behavioral disturbance, mild cognitive impairment, muscle weakness, oral phase dysphasia, cognitive communication deficit, hypertension, major depressive disorder, hyperlipidemia, anxiety disorder, atherosclerotic heart disease, angina pectoris, gastro-esophageal reflux disease, osteoarthritis, and other abnormalities of gait and mobility. Review of the 06/30/19 quarterly statement for Resident #20's trust account, from 04/04/19 through 06/11/19 revealed Resident #20's balance was over the $2,000.00 limit set by Medicaid. On 06/05/19 Resident #20's balance was $3,147.21. The balance on the 06/30/19 quarterly statement was $2,042.21. There was no evidence of a spend down notification being provided to Resident #20 or representative from 04/04/19 through 06/30/19. Review of the facility Resident Fund Quarterly Account Audit form, dated 07/12/19, for Resident #20's account revealed a balance of $2,042.21 and a spend down notification documenting from the period of 04/01/19 through 06/30/19 the balance was more than the $1,800.00 balance. Review of the current resident trust account balances revealed Resident #20 had a current balance of $2,063.08 as of 07/18/19. Interview on 07/18/19 at 11:54 A.M., Business Office Manager (BOM) #239 and Administrative Assistant (AA) #290 verified the facility only notifies residents quarterly of their account balances. BOM #239 and AA#290 verified Resident #20's accounts was over the Medicaid limit and the residents could become ineligible for the Medicaid Program. BOM #239 stated the families had been notified of the need to spend down, but not responded. BOM #239 and AA #290 verified the facility should be looking at the funds more often and not allow the funds to be in excess of the Medicaid limit. BOM #350 and AA #250 verified the facility only sent out the spend down notices quarterly and verified spend down notices were not sent out when the resident ' s balance was within $200.00 of the Medicaid limit. Review of the facility policy titled Resident Trust, effective date 07/01/14, verified the custodian is responsible to notify the resident or responsible party whenever their funds are within $200.00 of their resource limit. 2. Review of the medical record of Resident #43 revealed an admission date of 06/04/19. Diagnoses included chronic obstructive pulmonary disease, weakness, other abnormalities of gait and mobility, dysphagia, hyperlipidemia, hypokalemia, nausea, pain, hearing loss, restless leg syndrome, emphysema, gastro-esophageal reflux disease, major depressive disorder, anxiety disorder, hypertension and a history of nicotine dependence. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 2 of 11 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 365882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springmeade Healthcenter 4375 South County Road 25 A Tipp City, OH 45371 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)

F 0569 Level of Harm - Minimal harm or potential for actual harm Review of the 06/30/19 quarterly statement for Resident #43's trust account, from 05/07/19 through 06/11/19 revealed Resident #43's balance was over the $2,000.00 limit set by Medicaid. On 05/31/19 Resident #43's balance was $2,403.73. The balance on the 06/30/19 quarterly statement was $3,583.73. There was no evidence of a spend down notification being provided to Resident #43 or representative from 04/04/19 through 06/30/19. Residents Affected - Few Review of the facility Resident Fund Quarterly Account Audit form, dated 07/12/19, for Resident #43's account revealed a balance of $3,583.73 and a spend down notification documenting from the period of 04/01/19 through 06/30/19 the balance was more than the $1,800.00 balance. Review of the current resident trust account balances revealed Resident #43 had a current balance of $3,634.76 as of 07/18/19. Interview on 07/18/19 at 11:54 A.M., BOM #239 and AA #290 verified the facility only notifies residents quarterly of their account balances. BOM #239 and AA#290 verified Resident #20's accounts was over the Medicaid limit and the residents could become ineligible for the Medicaid Program. BOM #239 stated the families had been notified of the need to spend down, but not responded. BOM #239 and AA #290 verified the facility should be looking at the funds more often and not allow the funds to be in excess of the Medicaid limit. BOM #350 and AA #250 verified the facility only sent out the spend down notices quarterly and verified spend down notices were not sent out when the resident ' s balance was within $200.00 of the Medicaid limit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 3 of 11 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 365882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springmeade Healthcenter 4375 South County Road 25 A Tipp City, OH 45371 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)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview; the facility failed to provide the resident/resident representative the facility's bed hold and reserve bed payment policy when the resident representative elected to have the resident transferred to the hospital. This affected one (#102) of two residents reviewed for hospitalization. The census was 106. Findings include: Review of the medical record for Resident #102 revealed the resident was admitted to the facility on [DATE]. Diagnoses include metabolic encephalopathy, hypertension, cognitive communication deficit, and atrial fibrillation. The medical record revealed Resident #102's payer source was Medicare. Review of a progress note dated 05/05/19 at 11:08 A.M. revealed the resident refused all medication after several attempt. Documentation revealed the residents family member and physician was made aware of the medication refusal. Review of a progress note dated 05/05/19 at 11:32 A.M. revealed the resident's family member insist the resident be sent out to the hospital. Review of a progress note dated 05/05/19 at 12:24 P.M. revealed the resident left the facility via wheelchair with the family member, without incident. Review of the medical record for Resident #102 revealed no evidence of the bed hold notice and reserve bed payment policy being given to the resident or the resident representative. Interview on 07/18/19 at 9:52 A.M. with the Director of Nursing (DON) verified the bed hold notice policy was not given to Resident #102 or the resident representative. The DON revealed the bed hold notice was not given because the resident went to the hospital per a family members request. The DON verified the resident did not leave against medical advice (AMA) and had planned to return to the facility after being evaluated and treated at the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 4 of 11 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 365882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springmeade Healthcenter 4375 South County Road 25 A Tipp City, OH 45371 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)

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were submitted to the Centers for Medicaid/Medicare Services (CMS) for one (Resident #2) of one resident reviewed for MDS submission. The facility census was 106. Residents Affected - Few Findings include: Review of the medical record of Resident #2 revealed an admission date of 02/14/19. Diagnoses included displaced fracture of left femur, displaced transcondylar fracture of right humerus, muscle weakness, dysphasia, oropharyngeal phase, cognitive communication deficit, hypertension, gastro-esophageal reflux disease without esophagitis, bronchitis not specified chronic or acute, chronic obstructive pulmonary disease, hypo-osmolality and hyponatremia, old myocardial infarction, unspecified dementia without behavioral disturbance, and chronic kidney disease. The resident discharged on 03/23/19. Review of Resident #2's five-day/other MDS assessment revealed an assessment reference date (ARD) date of 02/21/19 and a completed dated of 03/20/19. There was no evidence this assessment was transmitted to the CMS data system. Review of Resident #2's discharged MDS assessment revealed an ARD date of 03/23/19 and a completed date of 03/27/19. There was no evidence this assessment was transmitted to the CMS data system. Interview on 07/17/19 at 3:53 P.M., MDS Nurse #288 verified Resident #2's five-day MDS assessment was completed late and neither the five day or the discharge MDS assessments were submitted to the CMS system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 5 of 11 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 365882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springmeade Healthcenter 4375 South County Road 25 A Tipp City, OH 45371 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)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview; the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. This affected two (#79 and #93) of 22 resident records reviewed for accuracy of MDS assessments. The census was 107. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #79 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness, hypotension, diabetes mellitus type two, obstructive sleep apnea, osteoarthritis, hypertension, hyperlipidemia, heart disease, and bipolar two disorder. Review of the medication administration record dated 06/19 and 07/19 revealed no evidence Resident #79 had orders for or was administered antibiotic medication from 06/30/19 to 07/06/19. Review of a 30 day MDS assessment dated [DATE], revealed Resident #79 was administered antibiotic medication on five days during the seven day reference period. Interview on 07/17/19 at 10:16 A.M. with MDS Nurse #288 revealed Resident #79 was not administered antibiotic medication from 06/30/19 to 07/06/19. MDS nurse #288 verified the 30 day MDS assessment dated [DATE] was not accurate. 2. Review of the medical record of Resident #93 revealed an admission date of 06/04/19. Diagnoses included chronic kidney disease, urinary tract infection, weakness, cognitive communication deficit, dysphagia, dysphagia, malignant neoplasm of the prostate, anemia, hypothyroidism, type two diabetes mellitus, hypokalemia, major depressive disorder, severe with psychotic features, anxiety disorder, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the five day MDS assessment, dated 07/02/19, revealed Resident #93 was given an anticoagulant six days of the seven day reference period. Review of the June 2019 and July 2019 MAR for Resident #93 revealed no anticoagulant had been administered. Interview on 07/17/19 at 03:34 P.M. with MDS Nurse #288 verified Resident #93's 07/02/19 MDS assessment was coded incorrectly for the administration of an anticoagulants. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 6 of 11 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 365882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springmeade Healthcenter 4375 South County Road 25 A Tipp City, OH 45371 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on medical record review, staff interview, observation, and review of facility policy, the facility failed to provide care to the gastrostomy tube (G Tube) insertion site for one (#309) of two residents in the facility and reviewed for G Tube care. The facility census was 106. Findings include: Review of the medical record for Resident #309 revealed an admission date of 07/05/19. Diagnoses include respiratory failure, aphasia, dysphagia following cerebral infarction and type two diabetes mellitus. Review of the July 2019 physician orders, medication administration record (MAR), and treatment admiration record (TAR) revealed no order for the care of the G tube site. Interview on 07/15/19 at 2:29 P.M. with Resident #309's husband revealed he had never observed any nurse clean around his wife's G tube. The spouse stated there was crusty material around the tube insertion site. Observation on 07/15/19 2:40 P.M. of Resident #309's G tube, revealed there was no dressing around the G Tube and there was dried, crusty matter around the G Tube insertion site. Observation on 07/17/19 at 11:21 A.M. of Resident #309's G Tube revealed there was no dressing around the G Tube and there was more dried, crusty matter around the insertion site. Interview on 07/17/19 at 12:00 P.M., Licensed Practical Nurse (LPN) #455 verified there was no dressing around Resident #309's G Tube and there was dried, crusty matter around the tube insertion site. She also verified there was no treatment for the care of the G Tube. Review of the facility policy titled Gastrostomy Tube Care Policy, dated 08/17, revealed staff were to cleanse around the tube at the insertion site with a cotton tipped applicator moistened with soap and water and to place a precut gauze, or other ordered, dressing around the insertion site as applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 7 of 11 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 365882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springmeade Healthcenter 4375 South County Road 25 A Tipp City, OH 45371 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview, the facility failed to offer/provide non-pharmacological interventions prior to the administration of as needed (prn) psychotropic medication. This affected one (#79) of five residents reviewed for unnecessary medication. The facility identified 28 residents receiving antianxiety medication. The census was 106. Findings include: Review of the medical record for Resident #79 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness, hypotension, diabetes mellitus type two, obstructive sleep apnea, osteoarthritis, hypertension, hyperlipidemia, heart disease, and bipolar two. Review of the care plan dated 06/28/19, revealed Resident #79 was at risk for side effects and complications of psychotropic drug use related to anxiety. Interventions include offer, monitor, and document any non-pharmacological interventions used to deter behaviors prior to the administration of medication. Review of Resident #79's physician orders dated 06/08/19 revealed an order for Ativan (antianxiety medication) 0.5 milligram (mg) one tablet by mouth every six hours as needed for anxiety. Review of the medication administration record (MAR), dated 07/19, revealed Resident #79 was administered Ativan on 07/01/19, 07/02/18, 07/03/19, 07/04/19, 07/05/19, 07/06/19, 07/07/19, 07/08/19, 07/09/19, 07/10/19, 07/11/19, 07/12/19, 07/14/19, and 07/16/19. There was no evidence any non-pharmacological interventions were offered or provided to Resident #79 prior to the administration of the prn ativan. Interview on 07/17/19 at 10:03 A.M., Licensed Practical Nurse (LPN) #250 revealed prior to administrating a resident prn medication, non pharmacological intervention should be offered. The LPN further revealed non-pharmacological interventions were documented on the MAR and sometimes in the residents' progress notes. LPN #250 verified the medical record for Resident #79 contained no evidence non-pharmacological interventions were offered to the resident prior to the administration of prn Ativan on 07/01/19, 07/02/18, 07/03/19, 07/04/19, 07/05/19, 07/06/19, 07/07/19, 07/08/19, 07/09/19, 07/10/19, 07/11/19, 07/12/19, 07/14/19, and 07/16/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 8 of 11 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 365882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springmeade Healthcenter 4375 South County Road 25 A Tipp City, OH 45371 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)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, and staff interview, the facility failed to administer insulin as ordered by the physician. This affected one (#63) of one residents observed for insulin administration. The census was 106. Residents Affected - Few Finding include: Observation and interview on 07/17/17 at 8:38 A.M. of Licensed Practical Nurse (LPN) #295 revealed the LPN was preparing insulin for Resident #63. LPN #295 reported Resident #63's finger stick blood sugar was 201 and the resident was to be administered, per subcutaneous injection, a total of eight units of Novolog (aspart) insulin. Continued observation revealed LPN #295 withdrew nine units of Novolog insulin into the syringe. LPN #295 then walked into Resident #63's room, donned gloves, and cleansed the residents injection site with an alcohol prep pad. The LPN was preparing to inject the medication. The surveyor then asked LPN #295 to verify the insulin dose that was about to be administered before continuing with the procedure. LPN #295 walked out of the residents room, verbalized the resident was to be administered eight units of Novolog, and looked a the syringe to verify the dose. The LPN verified the syringe contained nine units of insulin. LPN #295 then removed one unit of insulin from the syringe, returned to the resident's room, and administered eight units of Novolog insulin to Resident #63. Review of the medical record for Resident #63 revealed the resident was admitted to the facility on [DATE]. Diagnoses include anxiety, anemia, diabetes mellitus type two, and muscular dystrophy. Review of physician orders dated 06/05/18 revealed Resident #63 was to be administered insulin aspart solution 100 units per milliliter (units/ml); inject seven units subcutaneously with meals at 8:00 A.M., 12:00 P.M., and 5:00 P.M. for diabetes mellitus. Review of a physician order dated 10/08/17, revealed Resident #63 was to be administered insulin aspart solution inject subcutaneous before meals and at bedtime per sliding scale for diabetes mellitus. The sliding scale was 151-200 give two units, 201-250 give four units, 251-300 give six units, 301-350 give eight units, 351-400 give 10 units. Interview on 07/17/19 at 10:25 A.M. with LPN #295 revealed Resident #63 had physician orders for a routine dose of aspart insulin which was seven units. Additionally the resident received insulin per the sliding scale. LPN #295 revealed for a blood sugar reading of 201, the resident should have received an additional four units for a total of 11 units of aspart insulin. LPN #295 verified Resident #63 was administered eight units of aspart insulin on 07/17/18 at 8:38 A.M. The LPN further verified Resident #63 was administered the wrong dose of insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 9 of 11 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 365882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springmeade Healthcenter 4375 South County Road 25 A Tipp City, OH 45371 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)

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and physician interview, and review of facility policy, the facility failed to notify the physician of abnormal laboratory results for one (#316) of seven residents reviewed for unnecessary medications. The total resident census was 106. Findings include: Review of the medical record of Resident #316 revealed an admission date of 07/09/19. Diagnoses included agranulocytosis secondary to cancer chemotherapy, diffuse large B-cell lymphoma, hypothryroidism, hyperlipidemia, hypertension, hyponatremia, seasonal allergic rhinitis, gastro-esophageal reflux disease, Barrett's esophagus without dysplasia, abdominal hernia without obstruction or gangrene, polyarthritis, and benign prostatic hyperplasia. Review of the hospital transfer orders upon admission on [DATE] included laboratory orders for a Complete Blood Count (CBC) and a Comprehensive Metabolic Panel (CMP) to be completed on 07/09/19. Review of the orders verified with the facility attending physician, Medical Director #231, dated 07/09/19, revealed the laboratory orders were changed to have the CBC and CMP obtained on next lab draw day which was 07/12/19. Review of the laboratory report revealed the blood sample was collected from Resident #316 on 07/12/19 at 11:15 A.M. The lab report was faxed to and received by the facility on 07/12/19 at 2:01 P.M. The report reflected the resident's sodium level was 121 which reflected a low level outside the normal reference range of 135-148 milliequivalents per litre (mEq/L). There was no evidence in the record this abnormal laboratory test was reported to the physician. Interview on 07/15/19 at 2:00 P.M., Medical Director #231 stated she usually comes into the facility every Friday and nursing staff put laboratory reports on her clipboard to be reviewed. Medical Director #231 stated she was not in Friday 07/12/19 when the laboratory results for Resident #316 were faxed to facility. She verified the nursing staff did not call her with the abnormal laboratory results. She went on to state the sodium level of 121 was low, but not critically low, especially as the resident had a diagnosis of cancer and was receiving chemotherapy. Medical Director #231 stated she would not have transferred the resident back to the hospital, but would have expected the nursing staff to notify her of the abnormal results. Interview on 07/18/19 at 12:10 P.M. with Unit Manager Registered Nurse (UMRN) #200 verified Resident #231's laboratory results of 07/12/19 were put on Medical Director #231's clipboard for review that day. When the physician did not come in, the nurse on duty should have been reported the abnormal sodium level to Medical Director #231 or Certified Nurse Practitioner (CNP) #237. Review of the facility policy titled Notification of Change, with revision date of 06/19, reflected the physician and family were to be notified of abnormal laboratory work/results outside the clinical reference range as provided by the facility laboratory. Laboratory tests are to be reported by text, paging, or during physician visit. This deficiency substantiates Complaint Number OH00105663. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 10 of 11 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 365882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springmeade Healthcenter 4375 South County Road 25 A Tipp City, OH 45371 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review; the facility failed to ensure staff maintained good infection control practices, including hand hygiene, while administering medication. This affected two (#37 and #63) of five resident observed during medication administration. The census was 106. Residents Affected - Few Findings include: Observation on [DATE] from 8:24 A.M. to 8:46 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #295 was preparing medication for Resident #37. While removing medication from the packages, one of Resident #37's medication tablets fell onto the medication cart. LPN #295 picked up the tablet off of the cart, with ungloved fingers and placed the tablet into the medication cup. LPN #295 then walked to Resident #37's room and gave the resident the cup of medication and a cup of water. While Resident #295 was taking the medication, LPN #295 tidied up the resident's bedside table, which included placing two plastic cups in the trash can. After Resident #37 had swallowed all of the medication the resident gave LPN #295 the cup of water from which the resident had been drinking. LPN #295 placed the cup in the trash can. LPN #295 then left the residents room, without washing hands, and returned to the medication cart to prepare the next resident's medication. Without washing hands the LPN began to gather medication for Resident #63. LPN #295 prepared Resident #63's medication, which included oral tablets and a subcutaneous injection. After the medication had been prepared for Resident #63 the LPN gathered the medication and a pair of gloves and entered Resident #63's room. LPN #295 then gave Resident #63 the oral medication, donned gloves, adjusted the subcutaneous injection dose, and administered the subcutaneous injection. LPN #295 removed the gloves and returned to the medication cart without washing hands. Interview on [DATE] at 8:47 A.M., LPN #295 verified the LPN had picked up a tablet that had been dropped on the medication cart with bare fingers. Additionally, the LPN verified the tablet was then placed into Resident #37's medication cup, which was administered to the resident. LPN #295 verified the LPN did not wash hands after administering medication to Resident #37 or before preparing or administering medication to Resident #63. LPN #295 revealed when medication was dropped onto the cart, the medication should not be picked up with bare fingers and placed in the cup for administration. The LPN further revealed hands should be washed before and after providing any resident care. Review of the policy titled Medication Administration, dated 06/17, revealed hands should be cleansed appropriately prior to preparing a residents medication for administration. When preparing medication for administration the medication should never be touched by fingers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 11 of 11