Health inspection·June 23, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #86 had severely impaired cognition. Resident #86 required extensive assistance of one person for eating. Review of a care plan dated 10/31/19, revealed Resident #86 required assistance with activities of daily living (ADL) related to impaired vision, impaired hearing, neuropathy, and dementia. Interventions included the resident will feed self a portion of each meal every day and allow resident to participate in care and timing/order of care received. Review of a care plan dated 02/21/22, revealed Resident #86 was at risk for decline in malnutrition/dehydration status related to advanced age, weakness, weight loss trend and impaired/hearing/vision. Interventions included assist resident as needed with eating and encourage resident to have adequate food and fluid intake Review of a care plan dated 03/01/22, revealed Resident #86 was admitted to hospice on 02/14/22 with terminal diagnosis of cerebral atherosclerosis with services being provided in the facility. The goal was to have comfort level maintained and be emotionally supported during Resident #86's declining condition. Interventions included assist with ADL's and provide comfort measures as needed, monitor for decreased appetite, and nursing home staff to provide care to resident daily and as needed. Observation on 06/21/22 at 1:08 P.M. of Resident #86 in the dining room revealed the resident was in a tilt and space wheelchair sitting at a table with two other residents. The two other residents were eating the afternoon meal. Resident #86's meal tray was observed on the table, placed out of Resident #86's reach, with all food items covered. Resident #86 was awake and running both hands across the table top repeatedly. Continued observation revealed, at 1:24 P.M. Certified Nursing Assistant (CNA) #722 sat down in a chair next to Resident #86. CNA #722 pulled the meal tray within reach of the CNA and Resident #86, and began cutting up a sandwich for Resident #86. Resident #86 had stopped running his/her hands across the table after the staff member had sat down and started to prepare the meal tray. After three minutes of cutting up the sandwich, CNA #722 gave Resident #86 a bite of food. Still sitting next to Resident #86, CNA #722 informed CNA #752, who was standing on the other side of the room, that CNA #722 would need to leave the dining room in 10 minutes for an appointment. CNA #722 then gave Resident #86 another bite of food. Continuing to sit next to Resident #86, CNA #722 again informed CNA #752 of the need to leave the dining room in 10 minutes for an appointment. CNA #752 responded to CNA #722 by telling CNA #722 that CNA #722 would need to remain in the dining room to assist resident's with the meal until the meal was completed. Continued observation at 1:27 P.M. revealed temporary nurse aide (TNA) #713 entered the dining room and went to assist a resident who was located at a table next to Resident #86. CNA #722 informed TNA #713 of the need for CNA #722 to leave the dining room for an appointment and asked TNA #713 to assist Resident #86 with eating. The continuous observation revealed Resident #86 had been given two bites of the sandwich at that time and CNA #722 had not attempted to assist Resident #86 with any other food or drink items located on the meal tray. The observation revealed CNA #722 then left the dining room and TNA #713 sat down next to Resident #86. Further observation of Resident #86 revealed TNA #713 assisted Resident #86 with one bite of the sandwich, then TNA #713 then pushed the meal tray away from Resident #86 and left the dining room. Continued observation on 06/21/22 at 1:32 P.M. of Resident #86 revealed TNA #713 returned to the dining room, sat down next to Resident #86, and began to assist Resident #86 with eating. Resident #86 was offered food and drink items by TNA #713 and accepted the items. Interview on 06/21/22 at 1:34 P.M. with CNA #752 verified CNA #722 was assisting Resident #86 with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 2 of 10 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 06/23/2022 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the meal. CNA #752 verified, while CNA #722 was assisting Resident #86 with eating, CNA #722 informed CNA #752 of the need to leave the dining room for an appointment on two occasions. CNA #752 reported after the second time CNA #722 mentioned the need to leave for an appointment, CNA #752 informed CNA #722 of the need to remain in the dining room until the completion of assisting residents with eating. Interview with CNA #752 revealed CNA #722 was wanting to leave the dining room because the facility was providing staff with massages for nurses week and CNA #722 was scheduled for a massage at the same time CNA #722 was assigned to assist resident's in the dining room. CNA #752 revealed it was not appropriate for CNA #722 to talk about the need to leave the dining room for an appointment while sitting next to and assisting Resident #86 with the meal. Interview on 06/21/22 at 1:37 P.M. with CNA #722 revealed the facility was providing staff with massages for nurses week. CNA #722 verified, while assisting Resident #86 with eating, CNA #722 had told another CNA of the need to leave the dining room for an appointment. CNA #722 verified the appointment was the massage. CNA #722 verified CNA #722 stopped assisting Resident #86 with the meal to leave the dining room for the massage. CNA #722 reported after leaving the dining room for the massage, the nurse had informed CNA #722 that it was to busy for CNA #722 to be going to the massage appointment. CNA #722 reported it was not appropriate for the CNA #722 to be discussing with another CNA the need to leave the dining room while assisting a resident with the meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 3 of 10 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 06/23/2022 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview, the facility failed to notify the resident/resident representative in writing of the reason for transfer/discharge to the hospital. This affected one (Resident #36) out of two residents reviewed for hospitalization. The census was 95. Findings include: Review of medical record for Resident #36 revealed an admission date of 08/11/21 with diagnoses including Alzheimer's disease, dementia, and atrial fibrillation, and congestive heart failure. Review of the medical record for Resident #36 revealed the resident had severe cognitive impairment. Further review of the medical record for Resident #36 revealed she was hospitalized on [DATE]. There was no evidence Resident #36's representative was notified in writing of the reason for the transfer to the hospital. Interview on 06/22/22 at 3:55 P.M. with the Director of Nursing verified there was no evidence Resident #36's representative was notified in writing of the reason for the transfer/discharge to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 4 of 10 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 06/23/2022 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** 2. Review of medical record for Resident #36 revealed an admission date of 08/11/21 with diagnoses including Alzheimer's disease, dementia, and atrial fibrillation, and congestive heart failure. Review of the medical record for Resident #36 revealed the resident had severe cognitive impairment. Further review of the medical record for Resident #36 revealed she was hospitalized on [DATE]. There was no evidence Resident #36's representative was notified of the facility bed hold policy. Interview on 06/22/22 at 3:55 P.M. with the Director of Nursing verified there was no evidence of Resident #36's representative having been notified of the bed hold notice policy for Resident #36's hospitalization/discharge on [DATE]. Based on resident record review and staff interview, the facility failed to notify residents and/or resident representatives of the facility's bed hold policy when a resident was transferred to the hospital. This affected two (Resident #95 and #36) out of two residents reviewed for hospitalization. The census was 95. Findings include: 1. Review of the medical record for Resident #95 revealed Resident #95 was admitted to the facility on [DATE]. Diagnoses includes sepsis, urinary tract infection, diabetes mellitus type two, and compression fracture of the lumber vertebra. The resident discharged from the facility on 05/03/22. Review of a progress note dated 05/03/22 at 2:15 P.M. revealed Resident #95 was transferred to the hospital per the families request related to an abnormal radiology doppler report. Review of the medical record for Resident #95 revealed the medical record revealed no evidence of Resident #95 and/or Resident #95's representative having been notified of the bed hold notice policy for Resident #95's hospitalization dated 05/03/22. Interview on 06/22/22 at 3:55 P.M. with the Director of Nursing verified Resident #95's medical record contained no evidence Resident #95 and/or Resident #95's representative having been notified of the bed hold policy for Resident #95's hospitalization/discharge on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 5 of 10 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 06/23/2022 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 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 observation, resident record review, and staff interview, the facility failed to ensure a resident was provided adequate positioning while seated in a wheelchair. This affected one (Resident #86) out of three residents reviewed for positioning. The census was 95. Residents Affected - Few Finding include: Review of the medical record for Resident #86 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, peripheral autonomic neuropathy, congestive heart failure, legal blindness, and weakness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #86 had severely impaired cognition. Review of the assessment revealed Resident #86's mobility devices included a walker and a wheelchair. The assessment further revealed Resident #86 was not steady and was only able to stabilize with human assistance when moving from a seated to standing position, walking (with assistive devices), and surface to surface transfers. Review of the care plan dated 10/31/19, revealed Resident #86 required assistance with activities of daily living (ADL) related to impaired vision, impaired hearing, neuropathy, and dementia. Interventions included provide adaptive/safety equipment as needed, requires extensive assistance with ambulation, ambulates with the use of a walker or wheelchair, needs supervision for direction secondary to impaired vision, and requires extensive assistance of one for transfers. Review of a care plan dated 03/01/22, revealed Resident #86 was admitted to hospice on 02/14/22 with terminal diagnoses of cerebral atherosclerosis with services being provided in the facility. The goal was to have comfort level maintained and be emotionally supported during declining condition. Interventions included assist with ADL, provide comfort measures as needed, and hospice to provide specialty equipment as needed. Review of a hospice nurse visit progress note dated 06/16/22 at 12:10 P.M., revealed Resident #86 was resting in a tilt and space wheel chair with legs hanging down. Documentation revealed a request was made for a foot cradle for the foot pedals. The progress note revealed care was collaborated with Registered Nurse (RN) #725. Observation on 06/21/22 at 9:00 A.M. of Resident #86 revealed Resident #86 was seated in a tilt and space wheelchair (a reclining wheelchair which has a seat surface that can be tilted in various angles) across from the 300 hallway nurses station. The observation revealed there were no foot pedals on the wheelchair and Resident #86's lower legs and feet were dangling from the wheelchair seat and were unable to reach the floor. Resident #86's feet were observed to be dusky blue in color. Continued observations of Resident #86 on 06/21/22 between 9:00 A.M. and 1:00 P.M. revealed Resident #86 was in the tilt and space wheelchair, seated across from the nurses station with no foot pedals. Interview on 06/21/22 at 1:00 P.M. with Certified Nurse Aide (CNA) #781 verified Resident #86 was sitting in a tilt and space wheelchair without foot pedals. The CNA verified Resident #86's lower legs and feet were dangling from the wheelchair seat and were not touching the floor. The CNA revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 6 of 10 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 06/23/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the foot pedals were not used because Resident #86 would swing her legs while in the wheelchair which would cause bruising from hitting the pedals. Interview on 06/21/22 at 1:06 P.M. with RN #725 verified Resident #86 was sitting in a tilt and space wheelchair without foot pedals on the wheelchair. The RN verified Resident #86's feet did not reach the floor. Continued interview with RN #725 revealed Resident #86 did not have the foot pedals on the wheelchair because the resident would take his/her feet off of the pedals and sometimes his/her feet would fall behind the pedals. The RN reported a foot cradle was needed. The RN further revealed hospice was responsible for providing Resident #86's equipment and the nurse was trying to get a foot cradle from hospice. The RN revealed Resident #86 had been using the tilt and space wheelchair for about a week. The RN did not know if the facility had a foot cradle that the resident could use until a foot cradle was supplied by hospice. Event ID: Facility ID: 365882 If continuation sheet Page 7 of 10 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 06/23/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility documentation review and staff interview the facility failed to maintain appropriate water temperatures. This had the potential to affect 83 out of 95 residents in the facility. There were 12 residents (Resident #17, #18, #22, #24, #48, #51, #54, #58, #69, #78, #86, and #87) who did not have access to the water in the front bathroom, room [ROOM NUMBER], room [ROOM NUMBER], 100 hall shower room, and 200 hall shower room. The facility census was 95. Findings include: Observation on 06/22/22 at 5:20 P.M. of the front bathroom water temperature revealed a temperature of 126 degrees with the surveyor's thermometer. Observation on 06/22/22 at 5:28 P.M. with the Maintenance Supervisor (MS) #755 revealed the water temperature in room [ROOM NUMBER] was 129 degrees fahrenheit and the water temperature in room [ROOM NUMBER] was 125.4 degrees fahrenheit with the facility's digital thermometer. The water temperature in the shower room on the 200 hall was 128 degrees fahrenheit. The temperature in the 100 hall shower room was 124.1 degrees. Interview on 06/22/22 at 5:48 P.M. with the Administrator and the Director of Nursing (DON) revealed all staff were notified of the temperature of the water and to take precautions with residents. The Administrator revealed staff were advised to not allow resident showers until the temperature concerns were resolved. The DON and Administrator revealed no residents have reported burns or complaints of hot water. The Administrator revealed MS #755 would remain in the facility until the water temperatures were at an acceptable temperature. Interview on 06/23/22 at 8:03 A.M. with MS #755 revealed the facility had a company working on the mixing valve in order to correct the problem with the water temperatures. MS #755 revealed he remained at the facility on 06/22/22 adjusting the mixing valve. MS #755 stated he called the service company to ensure the mixing valve was working. MS #755 revealed he was not able to provide documentation of water temperatures having been routinely completed in the facility. Review of the facility policy titled Water Temperatures, dated 02/2017, revealed water temperatures servicing resident and visitor areas should be maintained between 105 degrees and 120 degrees. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 8 of 10 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 06/23/2022 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 medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one resident (Resident #40) out of five residents reviewed for medication administration. The facility census was 95. Residents Affected - Few Findings include: Review of Resident #40's medical record revealed an admission date of 01/05/21. admission diagnoses included hemiplegia and hemiparesis following a cerebral infarction, heart failure, kidney failure, diabetes, and chronic respiratory failure. Review of Resident #40's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. Review of Resident #40's physician order dated 05/20/22 revealed Polyethylene Glycol (medication used to treat constipation) 3350 Electrolyte Solution Reconstituted 236 grams. The instructions read to give eight ounces by mouth one time a day for colonoscopy prep for one day. Drink one eight-ounce glass every twenty minutes until two liters are gone. Interview and observation on 06/21/22 at 11:22 A.M. with Resident #40 revealed he was scheduled to have a colonoscopy; however, it was not able to be completed due to his colon was not empty. Resident #40 pointed to a gallon jug of solution in which he was to have drunk it all prior to the colonoscopy. Resident #40 stated it was not administered as ordered. Resident #40 stated he drank two or three glasses of the solution and never received any more. Resident #40 denied refusing to drink the ordered solution. Resident #40 stated he arrived at the hospital for the colonscopy, and they were not able to complete the colonscopy due to his colon was not clean. Resident #40 stated the hospital did an enema, however, they were still unable to complete the colonoscopy. Observation on 06/21/22 at 11:25 A.M. of the gallon jug of polyethylene glycol electrolyte solution sitting on the floor at the foot of the Resident #40's bed revealed the jug was approximately three-fourths full. Interview on 06/23/22 at 1:35 P.M. with the Director of Nursing confirmed Resident #40 had not received the polyethylene glycol electrolyte solution as ordered. The Director of Nursing confirmed Resident #40 had not been able to have the colonoscopy completed as ordered. Review of the facility policy titled Medication Administration, dated 06/21/17, revealed medications are to be administered in accordance with standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 9 of 10 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 06/23/2022 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 Based on review of the facility water management program, staff interview, and review of a Centers for Medicare and Medicaid Services Survey and Certification memo, the facility failed to ensure preventive measures for Legionella were completed according to their water management plan. This had the potential to affect all 95 residents at the facility. The facility census was 95. Residents Affected - Many Findings include: Review of the facility binder titled Water Management Program for Building/Water Systems, dated 2021, revealed the facility was to obtain water temperatures weekly. Interview on 06/23/22 at 8:03 A.M. with the Maintenance Supervisor #755 confirmed the facility was not obtaining weekly water temperatures as per their water management program. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification memo 17-30-Hospitals/Critical Access Hospitals/Nursing Homes, last revised 07/06/18, revealed the facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1. Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; 2. Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit; and 3. Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Testing protocols are at the discretion of the provider. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365882 If continuation sheet Page 10 of 10