Inspection visit
Inspection
14 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 14 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through
support of resident choice.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident #76's medical record revealed an admission date of 02/16/23. Diagnoses included Parkinson's
disease, dementia, and muscle weakness.
Review of the plan of care initiated 02/16/23 revealed Resident #76 had an Activities of Daily Living (ADLs)
self-care performance deficit related to weakness, Parkinson's disease, and dementia. Interventions
included physical assistance with bathing and dressing and provide a sponge bath when full bath or shower
was not tolerated.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was
moderately cognitively impaired, required extensive assistance with dressing, and personal care. In
addition, it was very important for Resident #76 to be choose between a tub bath, shower, bed bath, or
sponge bath.
Review of the State Tested Nurse Aide (STNA) documentation from 04/09/23 through 05/09/23 revealed
Resident #76 received bed baths on 04/11/23, 04/14/23, 04/22/23, 04/23/23, 04/25/23, and 05/01/23 and a
shower on 05/09/23.
Interview on 05/07/23 at 2:44 P.M. with Resident #76 revealed while she had been provided bed baths, she
was unable to recall the last time she had a shower. Resident #76 stated she preferred showers to bed
baths and felt refreshed after receiving a shower. Subsequent interview on 05/09/23 at 2:00 P.M. with
Resident #76 revealed she received a shower that day (05/09/23). Resident #76 again stated she preferred
a shower over a bed bath and felt much better after receiving a shower.
Interview on 05/09/23 at 2:36 P.M. with the Director of Nursing (DON) revealed all shower documentation
was completed in the Electronic Medical Record (EMR) and the facility did not have paper shower sheets.
The DON verified the documentation in Resident #76's medical record revealed from 04/09/23 through
05/09/23, the resident only received one shower, which was documented on 05/09/23. The DON confirmed
there was no evidence Resident #76 had received more than one shower since 04/09/23.
Review of the facility policy titled Activities of Daily Living, dated 05/07/20, revealed in accordance with the
comprehensive assessment, together with respect for individual resident needs and choices, the facility
provides care and services including, but not limited to, bathing, dressing, and grooming.
This deficiency represents non-compliance investigated under Complaint Number OH00139270.
(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 10
Event ID:
366042
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
366042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Spring Meadows Nursing, A Villa Center
1125 Clarion Ave
Holland, OH 43528
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 0561
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, review of Resident Council meeting minutes, resident and staff interview,
and review of the facility policy, the facility failed to ensure residents received showers per the resident's
preference. This affected two (Residents #32 and #76) of two residents reviewed for choices. The facility
census was 91.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #32 revealed an admission date of 04/24/19. Diagnoses
included end stage renal disease, duodenal ulcer, anxiety, rheumatoid arthritis, major depressive disorder,
heart failure, and osteoarthritis.
Review of the Minimum Data Set (MDS) assessment for dated 04/07/23 revealed Resident #32 was
cognitively intact. Resident #32 required supervision for activities of daily living and hands on assistance for
bathing.
Review of the shower documentation for Resident #32 dated March 2023 revealed resident did not receive
a shower on 03/12/23, 03/15/23, and 03/19/23.
Review of shower documentation for Resident #32 dated April 2023 revealed resident did not receive a
shower on 04/09/23 and 04/23/23.
Review of the Resident Council Minutes dated 04/17/23 revealed Resident #32 reported she was only
receiving one shower per week.
Interview on 05/07/23 at 11:38 A.M. with Resident #32 stated she only received one shower last week and
she was supposed to receive a shower twice a week on Wednesday and Saturday.
Interview on 05/10/23 at 9:29 A.M. with Director of Nursing (DON) verified showers were not documented
on 03/12/23, 03/15/23, 03/19/23, 04/09/23, and 04/23/23. The DON stated that resident prefers not to be
showered by a male state tested nursing aide (STNA) and could be the reason for the showers not being
given.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366042
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
366042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Spring Meadows Nursing, A Villa Center
1125 Clarion Ave
Holland, OH 43528
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of
Resident #28's medical record revealed an admission date of 07/26/20. Diagnoses included atrial
fibrillation, dysphagia, chronic kidney disease, bilateral below the knee amputation, peripheral vascular
disease, and neuromuscular bladder.
Review of Resident #28's quarterly MDS assessment dated [DATE] revealed the resident was cognitively
intact.
Review of Resident #28's care conferences revealed conferences were held on 08/01/22, and 05/03/23.
There were no other care conferences held in the year 2022 and only one thus far for the year 2023.
Interview on 05/08/23 at 11:53 A.M. with SSD #531 verified care conferences were not held quarterly for
Resident #28. SSD #531 stated she was working on getting care conferences caught up.
5. Review of Resident #56's medical record revealed an admission date of 12/09/20. Diagnoses included
Alzheimer's disease, diabetes mellitus, dementia, and coronary artery disease.
Review of Resident #56's quarterly MDS assessment dated [DATE] revealed she was unable to complete
the brief interview for mental status.
Review of Resident #56's most recent care plan revealed she had terminal/end stage prognosis related to
Alzheimer's disease was was under Hospice care.
Review of Resident #56's social service notes care conferences were held on 07/20/22, 10/31/22, and
01/11/23. There were no other care conferences held between January 2022 to June 2022 and no other
care conference was held this year besides 01/11/23.
Interview with the family member of Resident #56 on 05/08/23 at 10:30 A.M. revealed care conferences
were not being regularly for a long time.
Interview on 05/08/23 at 11:53 A.M. with SSD #531 verified care conferences were not held quarterly for
Resident #56. SSD #531 stated she was working on getting care conferences caught
6. Review of Resident #70's medical record revealed an admission date of 06/13/22. Diagnoses included
pressure ulcer, paraplegia, and blepharon conjunctivitis.
Review of Resident #70's quarterly MDS assessment dated [DATE] revealed the resident had a high
cognitive function.
Review of Resident #70's social service notes revealed care conference meeting was held only once on
02/01/23. Care conferences were not conducted in 09/2022 and 12/2022.
Interview on 05/08/23 at 11:53 A.M. with SSD #531 verified care conferences were not held quarterly for
Resident #70. SSD #531 stated she was working on getting care conferences caught
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366042
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
366042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Spring Meadows Nursing, A Villa Center
1125 Clarion Ave
Holland, OH 43528
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 0657
Level of Harm - Minimal harm
or potential for actual harm
7. Review of Resident #71's medical record revealed an admission date of 07/15/22. Diagnoses included
diabetes mellitus, malnutrition, acute kidney failure, acute renal failure, and a sacral pressure ulcer.
Review of Resident #71's social service notes revealed care conferences were held on 09/28/22 and
03/29/23. A care conference was not completed in 12/2022.
Residents Affected - Some
Interview on 05/08/23 at 11:53 A.M. with SSD #531 verified care conferences were not held quarterly for
Resident #71. SSD #531 stated she was working on getting care conferences caught
Review of the policy titled Care Plan Standard Guideline, dated 11/28/17, revealed the care plan will be
reviewed throughout the resident's stay upon admission, quarterly, and with changes in condition. The care
plans will be reviewed and revised at the care conference in collaboration with resident and/or resident
representative.
Based on record review, policy review, and family and staff interview, the facility failed to conduct quarterly
care conferences routinely. This affected seven (Residents #28, #32, #46, #56, #63, #70, and #71) of 10
residents reviewed for care planning. The facility census was 91.
Findings include:
1. Review of the medical record for Resident #32 revealed an admission date 04/24/19 with diagnoses
including end stage renal disease, type two diabetes, dependence on renal dialysis, anemia, duodenal
ulcer, anxiety, chronic kidney disease stage four, heart failure, and osteoarthritis.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively
intact.
Review of the care conference note dated 08/08/22 revealed Resident #32, social services, and activity
director attended the care conference.
Further review of the medical record revealed no care conferences were held between 08/08/22 and
02/24/23.
Review of the Interdisciplinary Care Conference dated 02/24/23 revealed Resident #32 and son was invited
to the care conference. The son did not attend.
Interview on 05/08/23 at 11:53 A.M. with Social Service Director (SSD) #531 verified care conferences
were not held quarterly for Resident #32. SSD #531 stated she was working on getting care conferences
caught up.
2. Review of the medical record for Resident #46 revealed an admission date 11/21/22. Diagnoses included
major depressive disorder, severe with psychotic symptoms, muscle weakness, muscle wasting and
atrophy, anxiety, insomnia, osteoarthritis, constipation, bipolar disorder, schizoaffective disorder,
gastro-esophageal reflux disease, and anorexia.
Review of the MDS assessment dated [DATE] revealed Resident #46 was cognitively intact.
Review of the Social Service Note for Resident #46 dated 11/22/22 revealed a 48-hour care
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366042
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
366042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Spring Meadows Nursing, A Villa Center
1125 Clarion Ave
Holland, OH 43528
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 0657
Level of Harm - Minimal harm
or potential for actual harm
conference held with Social Service Designee (SSD), MDS Coordinator and the resident's brother via
phone attended the care conference.
Further review of the medical record revealed no care conferences were held between 11/22/22 and
04/28/23.
Residents Affected - Some
Review of the Interdisciplinary Care Conference for Resident #46 dated 03/28/23 revealed the resident and
brother were invited to attend the care conference. The brother did not attend.
Interview on 05/08/23 at 11:53 A.M. with SSD #531 verified care conferences were not held quarterly for
Resident #46.
3. Review of the medical record for Resident #63 revealed an admission date of 08/05/22. Diagnoses
included Parkinson's disease, muscle wasting and atrophy, type two diabetes mellitus, morbid obesity,
anxiety, depression, and seasonal allergic rhinitis.
Review of the MDS assessment dated [DATE] revealed Resident #63 was cognitively intact.
Review of the Care Management note for Resident #63 dated 08/08/22 revealed the initial care conference
was held on 08/08/22.
Further review of the medical record revealed no care conferences were held between 08/05/22 to
05/02/23.
Review of the Interdisciplinary Care Conference note late entry for 05/02/23 revealed a care conference
was held on this day.
Interview on 05/08/23 at 11:53 A.M. with SSD #531 verified care conferences were not held quarterly for
Resident #63.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366042
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
366042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Spring Meadows Nursing, A Villa Center
1125 Clarion Ave
Holland, OH 43528
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
medical record review, observation, and resident and staff interview, the facility failed to ensure care and
maintenance was provided for a midline catheter. This affected one (#30) of one residents reviewed for
peripheral venous catheters. The facility census was 91.
Residents Affected - Few
Findings include:
Review of Resident #30's medical record revealed an admission date of 10/04/20 and a readmission date
of 05/05/23. Diagnoses included multiple sclerosis (MS), paraplegia, neuromuscular dysfunction of bladder,
acute pyelonephritis, and urinary tract infection (UTI).
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was
cognitively intact and had an indwelling catheter.
Review of the plan of care focus area initiated 10/22/22, revealed Resident #30 had a midline catheter to
the left upper extremity. Interventions included midline flushes and dressing changes as ordered.
Review of a hospital After Visit Summary (AVS) dated 05/05/23 revealed Resident #30 had an anterior left
upper arm peripheral IV with discharge instructions including sodium chloride flush, infuse 10 milliliters (ml)
into venous catheter in the morning and at bedtime for midline maintenance.
Review of a Nursing Evaluation dated 05/05/23 revealed Resident #30 had a midline catheter.
Review of the current physician orders revealed no orders for the care and maintenance of Resident #30's
midline catheter.
Observation and interview on 05/07/23 at 11:04 A.M. revealed Resident #30 had a midline catheter placed
on the inside of her left upper arm. There was no date on the dressing indicating when it was last changed.
Resident #30 stated she had been sick off and on for several months had had received antibiotics through
the midline catheter. Resident #30 stated she returned from the hospital a couple of days ago and facility
staff had not provided any type of care for the midline catheter.
Interview on 05/08/23 at 10:01 A.M. with State Tested Nurse Aide (STNA) #559 confirmed Resident #30
had a midline catheter placed to her left anterior upper arm.
Interview on 05/08/23 at 4:49 P.M. with Assistant Director of Nursing (ADON) #507 confirmed residents with
a peripheral venous catheter should have orders for the care and maintenance of the line, including
dressing changes and flushes. ADON #507 verified Resident #30 had no orders for the care and
maintenance of her midline catheter. Additionally, ADON #507 confirmed the hospital after visit summary,
dated 05/05/23, included instructions to flush the midline catheter with 10 milliliter (ml) sodium chloride
each morning and bedtime for maintenance. ADON #507 stated she would have the nurse get physician
orders for the care of Resident #30's midline catheter.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366042
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
366042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Spring Meadows Nursing, A Villa Center
1125 Clarion Ave
Holland, OH 43528
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, resident and staff interview, and policy review, the facility failed to ensure a resident was
provided with physician ordered wound healing supplement. This affected one resident (#28) of three
residents reviewed for pressure ulcers. The facility identified 11 residents with pressure ulcers. The facility
census was 91.
Residents Affected - Few
Findings include:
Review of Resident #28's medical record revealed an admission date of 07/26/20. Diagnosis included
chronic kidney disease, bilateral below the knee amputation, and peripheral vascular disease.
Review of Resident #28's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident was cognitively intact. There were no negative behaviors documented. Resident #28 had a stage
IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may
be present on some of the wound bed.)
Review of Resident #28's wound care notes dated 04/18/23 revealed the resident's sacral pressure ulcer
measured 2.43 centimeters (cm) in length by 1.79 cm wide by 0.6 cm. depth. On 05/08/23, the wound
measured 2.51 cm x 1.78 cm x 0.6 cm.
Review of Resident #28's physician's order dated 01/06/23 revealed an order for Abintra (a specialized
nutrition supplement for wound healing). Directions were to mix one packet with 210 milliliters of water.
Resident #28 was to have Abintra daily to assist with wound healing.
Review of the Medication Administration Record (MAR) dated March 2023 revealed Resident #28 did not
receive Abintra on 03/14/23, 03/19/23, 03/21/23, 03/22/23, 03/23/23, 03/24/23, 03/24/23, 03/25/23,
03/26/23, 03/27/23, and 03/28/23. The medication was documented with 09 which meant other/see nurses
notes. Review of the nurse's notes revealed no mention of why the medication was not administered.
Review of the MAR dated April 2023 revealed Resident #28 did not receive Abintra on 04/02/23, 04/15/23,
04/16/23, 04/17/23, 04/19/23, 04/20/23, 04/21/23, 04/25/23, 04/26/23, 04/27/23, 04/29/23, and 04/30/23.
The medication was documented with 09 and no explanation was found in the nurse's notes.
Review of the MAR dated May 2023 revealed Resident #28 did not receive Abintra on 05/01/23, 05/02/23,
05/03/23, and 05/24/23. The medication was documented as 09 and no explanation was found in the
nurses notes.
Interview with the Director of Nursing (DON) on 05/09/23 at 1:47 P.M. revealed the Abintra was only
available from a popular online service and it was difficult to order due to it being out of stock. She also
stated it was expensive for the facility to supply.
Review of an online store on 05/09/23 at 2:10 P.M. revealed Abinta was found readily available on the
online store and could be delivered to the facility on [DATE].
Interview with Resident #28 on 05/10/23 at 8:13 AM revealed she rarely received the Abintra and knew her
physician had ordered it.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366042
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
366042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Spring Meadows Nursing, A Villa Center
1125 Clarion Ave
Holland, OH 43528
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 0686
Review of the facility's undated policy titled Administering Medication Guidelines revealed medications and
treatments must be administered in accordance with the orders, including required timeframe.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366042
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
366042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Spring Meadows Nursing, A Villa Center
1125 Clarion Ave
Holland, OH 43528
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 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a
fistula was routinely monitored for a resident on dialysis. This affected one (#21) of one resident reviewed
for dialysis. The facility identified four residents who received dialysis. The facility census was 91.
Residents Affected - Few
Findings include:
Review of Resident #21's medical record revealed an admission date of 01/04/22 and a readmission date
of 11/02/22. Diagnoses included dysphagia, end stage renal disease, type II diabetes, peripheral vascular
disease, dependence on renal dialysis, depression, chronic obstructive disease (COPD), benign prostatic
hyperplasia without lower urinary tract symptoms, and spinal stenosis.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/12/23, revealed Resident #21 was
cognitively intact and received dialysis.
Review of the plan of care, initiated 10/04/22, revealed Resident #21 needed dialysis related to end stage
renal failure. Interventions included to monitor access site in left upper arm.
Review of the current physician orders revealed no orders to monitor Resident #21's fistula (dialysis access
site).
Interview on 05/09/23 at 10:26 A.M. with Licensed Practical Nurse (LPN) #571 confirmed Resident #21
received dialysis and had a left upper arm fistula for his dialysis access site. LPN #571 stated she
monitored Resident #21's vital signs, especially the resident's blood pressure. LPN #571 verified Resident
#21 had no physician orders to assess the resident's fistula for bruit and thrill and nursing did not document
any assessment of Resident #21's dialysis access site.
Review of the facility guidelines titled Dialysis undated, revealed post dialysis protocol included to check
fistula for bruit or thrill daily.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366042
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
366042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Spring Meadows Nursing, A Villa Center
1125 Clarion Ave
Holland, OH 43528
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on record review, policy review, and staff interview, the facility failed to ensure the medications
administered were documented accordingly in the medical record. This affected one (Resident #42) of five
residents reviewed for medications. The facility census was 91.
Findings include:
Review of the medical record for Resident #42 revealed an admission date 06/29/22. Diagnoses included
metabolic encephalopathy, muscle weakness, type two diabetes mellitus (DM), chronic obstructive
pulmonary disease (COPD), acute respiratory failure with hypoxia, acute kidney failure, retention of urine,
benign prostatic hyperplasia, ventricular tachycardia, Alzheimer's disease, dementia, depression,
hyperlipidemia, atherosclerotic heart disease of native coronary artery, cachexia, bell's palsy, syncope and
collapse, and dysphagia.
Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 04/06/23 revealed the resident
had severe cognitive impairment.
Review of the Medication Administration Record (MAR) for April 2022 revealed Resident #42 had no
documentation as to receiving the following medications at 7:00 A.M.: aspirin (treats mild pain) 81
milligrams (mg), docusate sodium (treats constipation) 100 mg, donepezil (treats Alzheimer's disease) 10
mg, enalapril (treats high blood pressure) 10 mg, insulin glargine (DM) 100 units/milliliter (ml) six units,
Lasix (diuretic) 20 mg, metoprolol succinate (treats high blood pressure) 12.5 mg, multivitamin, nifedipine
extended release (treats high blood pressure) 30 mg, rosuvastatin calcium (treats cholesterol) five mg,
senna plus (treats constipation) 8.6/50 mg, spironolactone (diuretic) 25 mg, hydralazine (treats high blood
pressure) 50 mg before lunch, cilostazole (vasodilator) 100 mg and tamsulosin (treats urinary retention) 0.4
mg on 04/02/23, 04/06/24, 04/12/23, 04/17/23, 04/26/23, and 04/27/23. Keflex (antibiotic) 500 mg not given
on 04/26/23 and 04/27/23.
Interview on 05/10/23 at 9:35 A.M. with the Director of Nursing (DON) verified the medications at 7:00 A.M.
were not documented as given on 04/02/23, 04/06/23, 04/12/23, 04/17/23, 04/26/23, and 04/27/23. The
DON stated the the nurses did not document they were administered and the DON will have them come in
to document they were administered. Assistant Director of Nursing (ADON) #507 verified the medications
not documented as administered as well.
Review of the policy titled Administering Medication Guideline not dated revealed ff a drug is refused,
withheld, or given at a time other than the scheduled time, the individual administering the medication must
document such in the medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366042
If continuation sheet
Page 10 of 10
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Back to topCitations
14 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
FAQ · About this visit
Common questions about this visit
What happened during the May 10, 2023 survey of SPRING MEADOWS NURSING, A VILLA CENTER?
This was a inspection survey of SPRING MEADOWS NURSING, A VILLA CENTER on May 10, 2023. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SPRING MEADOWS NURSING, A VILLA CENTER on May 10, 2023?
Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a t..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.