Inspection·November 2, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, hospital record review, review of facility incident report, and review of facility policy, the facility failed to report an injury of unknown origin to the state agency for Resident #23 and failed to report a resident to resident incident to the state agency for Resident #84. This affected two (#23 and #84) of three reviewed for abuse and neglect. The facility census was 84. Findings include 1. Review of Resident #23's medical record revealed an admission date of 10/04/20. Diagnoses included multiple sclerosis, anxiety, neuromuscular dysfunction, chronic pain, sepsis, displaced fracture of right femur for closed fracture, osteoporosis, and encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact and dependent for transfers. Review of the plan of care dated 10/26/23 revealed Resident #23 had an Activities of Daily (ADLs) self-care deficit, paraplegia, contractures of the bilateral lower extremities and weakness. Interventions included to provide assistance with ADLs. Additionally, the plan of care revealed Resident #23 had limited physical mobility related to paraplegia, contractures and scoliosis. Interventions included non-weight bearing and monitor for signs and symptoms of immobility. Review of a physician progress note dated 10/09/23 revealed Resident #23 endorsed significant right lower extremity pain and stated the fentanyl patch was not helpful. The physician recommended to consider increase of pregabalin, pain managed by Palliative care. Review of a nursing progress note dated 10/09/23 at 10:39 P.M. revealed Resident #23 had slow, slurred speech, elevated temperature, and stated she could not hear. On-call provider contacted and resident was sent to the hospital for further evaluation. Review of a hospital history and physical dated 10/09/23 revealed Resident #23 was seen due to a temperature of 101 degrees Fahrenheit (F), less talkative for the past one and one-half hours, and gets like this when she has a Urinary Tract Infection (UTI). Resident complained of pain all over, including head, chest, abdomen, and right leg. Resident #23 denied any injury or fall. Review of a radiology report, dated 10/10/23, and completed due to complaint of right leg pain, revealed Resident #23 had an intertrochanteric fracture of the proximal right femur (hip fracture). (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 9 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 11/02/2023 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)