Health 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). Page 1 of 9 366042 366042 11/02/2023 Spring Meadows Nursing, A Villa Center 1125 Clarion Ave Holland, OH 43528

F 0609 Level of Harm - Minimal harm or potential for actual harm Review of an Orthopedic Surgery Operative Report, dated 10/11/23, revealed the right proximal femur fracture was surgically repaired without complications. Review of Self-Reported Incidents, located in the Certification and Licensure System (CALS), revealed the facility did not report Resident #23's right femur fracture as an injury of unknown origin to the state agency. Residents Affected - Few Interview on 10/31/23 at 10:58 A.M. with Resident #23 revealed her leg and hip hurt her prior to going to the hospital, but stated she had chronic pain and was unable to decipher between new and existing pain. Resident #23 revealed she did not know how the fracture occurred and confirmed she did not have a fall or another injury at the facility. Resident revealed she had surgery at the hospital and was on a pain medication to help control pain. Interview on 10/31/23 at 11:45 A.M. with Assistant Director of Nursing (ADON) #135 revealed she did not have any documentation of how Resident #23 sustained the right femur fracture and did not know if it occurred at the facility or at the hospital. Interview on 10/31/23 at 4:20 P.M. with the Administrator, Director of Nursing (DON), and ADON #135 verified the facility did not report Resident #23's right femur fracture as an injury of unknown origin to the state agency because, although the resident complained of right leg pain prior to going to the hospital, it could not be proven Resident #23's fracture occurred at that facility, therefore, they would not need to report it as an injury of unknown origin. 2. Review of Resident #84's medical record revealed an admission date of 12/30/20. Diagnoses included epilepsy, dementia, macular degeneration, anxiety, psychoactive substance abuse, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 was cognitively intact and required supervision for mobility and transfers. Review of the care plan dated 10/11/23 revealed Resident #84 had cognitive delay related to dementia and encephalopathy with interventions to ask yes or no questions and monitor cognitive decline. Their was no mention in the residents care plan of a relationship between Resident #84 and a male resident. Review of incident report dated 08/07/23 revealed Resident #84 had reported to social services a male resident, #31, had been bringing her gifts and kissing her. Resident #84 stated the male resident made her uncomfortable by kissing her and sticking his tongue in her mouth. Resident #84 did not want to get Resident #31 in trouble, but but revealed he had made her uncomfortable by kissing her and sticking his tongue in her mouth and did not want it to happen again. Staff informed Resident #84 they would need to talk with Resident #31 to make sure he knew not to do this again. Review of Self-Reported Incidents, located in the Certification and Licensure System (CALS), revealed the facility did not report the Resident to Resident incident in August 2023. Interview on 11/01/23 at 10:10 A.M. with the Administrator revealed a grievance log entry was created for Resident #84 who had reported a male resident stuck his tongue in her mouth. Resident #84 revealed, at times, she would kiss this male resident on the cheek or a peck on the lips but the french kiss was uncomfortable and she did not want this to occur again. Resident #84 had reported to floor 366042 Page 2 of 9 366042 11/02/2023 Spring Meadows Nursing, A Villa Center 1125 Clarion Ave Holland, OH 43528

F 0609 Level of Harm - Minimal harm or potential for actual harm staff as well as Social Service Director (SSD) #183, who reported to the Administrator. The Administrator revealed staff spoke with Resident #31 regarding the situation and since Resident #84 did not report concerns and did not report being uncomfortable with the situation, he did not feel it needed to be reported to the state agency. The Administrator reviewed the incident report completed by staff and confirmed Resident #84 stated it made me feel uncomfortable. Residents Affected - Few Review of facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/28/17, revealed injuries of unknown origin included injuries that were not observed by any person or could not be explained by the resident and the injury is suspicious because of the extent of the injury or location of the injury. Sexual abuse was defined as any non-consensual sexual contact of any type with a resident. The abuse policy included steps the facility would take, which included reporting to the state agency. This deficiency represents non-compliance investigated under Complaint Number OH00147259. 366042 Page 3 of 9 366042 11/02/2023 Spring Meadows Nursing, A Villa Center 1125 Clarion Ave Holland, OH 43528

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based medical record review, resident interview, staff interview, review of hospital records, and review of facility policy, the facility failed to complete a thorough investigation after an injury of unknown origin was identified. This affected one (#23) of three residents reviewed for injury. The facility census was 84. Residents Affected - Few Findings include: 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). Review of an Orthopedic Surgery Operative Report, dated 10/11/23, revealed the right proximal femur fracture was surgically repaired without complications. Review of Self-Reported Incidents, located in the Certification and Licensure System (CALS), revealed the facility did not report Resident #23's right femur fracture as an injury of unknown origin to the state agency. Interview on 10/31/23 at 10:58 A.M. with Resident #23 revealed her leg and hip hurt her prior to going to the hospital, but stated she had chronic pain and was unable to decipher between new and existing pain. Resident #23 revealed she did not know how the fracture occurred and confirmed she did not have a fall or another injury at the facility. Resident revealed she had surgery at the hospital 366042 Page 4 of 9 366042 11/02/2023 Spring Meadows Nursing, A Villa Center 1125 Clarion Ave Holland, OH 43528

F 0610 and was on a pain medication to help control pain. Level of Harm - Minimal harm or potential for actual harm Interview on 10/31/23 at 11:45 A.M. with Assistant Director of Nursing (ADON) #135 revealed she did not have any documentation indicating where Resident #23's injury/fracture occurred, whether at the facility or after her transfer to the hospital. Residents Affected - Few Interview on 10/31/23 at 4:01 P.M. with the Administrator revealed the facility was under the impression Resident #23's right femur fracture occurred while hospital staff were providing care to her. The Administrator was unable to state where this information came from and had no evidence the fracture occurred after Resident #23 was transferred to the hospital. Interview on 10/31/23 at 4:20 P.M. with the Director of Nursing (DON), Administrator, and ADON #135 confirmed the physician saw Resident #23 on 10/09/23, prior to her hospitalization. While Resident #23 complained of uncontrolled and increased pain in her right lower extremity, it could not be proven Resident #23 had a fracture at the facility and, therefore, they were not required to initiate an investigation for an injury of unknown origin. After further discussion, the Administrator verified an injury of unknown origin was defined as an injury with unknown cause, which was why they needed to be reported and investigated. The DON stated if it was that big of a concern, the hospital should have reported the injury of unknown origin. Review of facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/28/17, revealed injuries of unknown origin included injuries that occurred when the source of the injury was not observed by any person or could not be explained by the resident, and the injury is suspicious because of the extent of the injury or location or the number of injuries over time. The abuse policy indicated injuries of unknown origin shall be promptly and thoroughly investigated. This deficiency represents non-compliance investigated under Complaint Number OH00147259. 366042 Page 5 of 9 366042 11/02/2023 Spring Meadows Nursing, A Villa Center 1125 Clarion Ave Holland, OH 43528

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 interview, staff interview, and review of facility policy, the facility failed to ensure dependent residents received showers according to their schedule and as needed. This affected three (#28, #87 and #88) of three residents reviewed for Activities of Daily Living (ADLs). The facility census was 84. Residents Affected - Few Findings included: 1. Review of Resident #28's medical record revealed an admission date of 08/29/23. Diagnoses included encephalopathy, muscle weakness, respiratory failure, diabetes, staph infection, heart disease, pressure ulcer sacral region, diabetic foot ulcer, vascular disease, altered mental status, and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact and required extensive assistance of one to two staff for mobility and transfers. Review of the medical record for the previous 30 days revealed Resident #28 only one shower documented as provided, which was on 10/23/23. Observation on 11/01/23 at 12:40 P.M. of Resident #28 revealed he had unkempt facial hair and his hair was uncombed and appeared greasy. Concurrent interview of Resident #28 revealed he had not been assisted with hygiene or showers in approximately one week. Follow-up interview on 11/02/23 at 12:50 P.M. with Resident #28 revealed he did not receive regular baths or showers, scheduled for twice weekly, and stated staff did not assist him with getting cleaned up in a timely manner. Resident #28 stated he had gone over one week without a bath. 2. Review of Resident #88's medical record revealed an admission date of 10/20/23 and a discharge date [DATE]. Diagnoses included spinal stenosis, weakness, muscle wasting, diabetic foot ulcer, chronic osteomyelitis, central cord syndrome, diabetes, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] was not finalized, but revealed Resident #88 was cognitively intact. Review of the medical record from 10/20/23 through 10/25/23 revealed no evidence Resident #88 received a shower during his admission at the facility. 3. Review of Resident #87's medical record revealed an admission date of 09/25/23 and a discharge date of 10/30/23. Diagnoses included malnutrition, muscle weakness, bacteriuria, urinary tract infection, COVID-19, pressure ulcer, sacral ulcer, Alzheimer's disease, dementia, anemia, and pneumonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was cognitively impaired and required extensive assistance of one to two staff for all mobility and transfers. Review of the medical record found no evidence Resident #87 received a shower or bed bath at any time in the previous 30 days. 366042 Page 6 of 9 366042 11/02/2023 Spring Meadows Nursing, A Villa Center 1125 Clarion Ave Holland, OH 43528

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/02/23 at 12:55 P.M. with Licensed Practical Nurse (LPN) #201 revealed staff documented showers and bed baths in the electronic medical record under tasks. Interview on 11/02/23 at 1:15 P.M. with the Director of Nursing (DON) revealed a change in documentation got things messed up related to task documentation, including showers. The DON provided weekly skin checks, but verified the skin checks did not indicate whether showers and/or bed baths were provided. The DON confirmed Resident #28 had one documented bed bath in the last 30 days and Residents #87 and #88 had no documented baths or showers. Interview on 11/02/23 at approximately 2:00 P.M. with the Administrator confirmed documentation provided was for skin checks and not shower sheets. The Administrator verified the facility had no evidence of showers being given to Residents #28, #87, and #88. Review of facility policy titled Bathing, undated, revealed each resident would be provided a bath or shower twice weekly to promote cleanliness and provide comfort. This deficiency represents non-compliance investigated under Complaint Numbers OH00147873 and OH00147931. 366042 Page 7 of 9 366042 11/02/2023 Spring Meadows Nursing, A Villa Center 1125 Clarion Ave Holland, OH 43528

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on review of physician orders, observations, resident interviews, staff interviews, and review of dietary spreadsheets, the facility failed to provide therapeutic diets according to physician order. This affected two (#51 and #28) of three residents reviewed for diabetic (carbohydrate consistent - CCD) diet orders, with the potential to affect 19 (#2, #5, #8, #10, #13, #16, #18, #22, #31, #38, #40, #42, #45, #48, #53, #69, #78, #80, and #89) additional residents identified by the facility with physician ordered CCD diets. The facility census was 84. Findings include: 1. Review of Resident #51's medical record revealed an admission date of 10/27/23. Diagnoses included hypotension, muscle weakness, diabetes, chronic obstructive pulmonary disease (COPD), and muscle atrophy. Review of current physician orders revealed Resident #51 was ordered a carbohydrate consistent (CCD) diet with no added salt. Interview on 11/01/23 at 12:02 P.M. with Resident # 51 revealed she recently admitted to the facility and was surprised she did not receive a diabetic diet (carbohydrate controlled/carbohydrate consistent - CCD) , as she was used to at home. Resident #51 stated she believed she received the same food items and portions as non-diabetic residents. Concurrent observation, with State Tested Nurse Aide (STNA) #203, verified Resident #51 was served a full plate of fettuccine alfredo with chicken, a scoop of broccoli, two slices of garlic bread, and a berry crumble dessert. 2. Review of Resident #28's medical record revealed an admission date of 08/29/23. Diagnoses included diabetes, encephalopathy, heart disease, diabetic foot ulcer, and heart failure. Review of current physician orders revealed Resident #28 was ordered a CCD diet with no added salt. Observation on 11/01/23 at 12:40 P.M. of Resident #28 revealed the resident was served a lunch plate full of fettuccine alfredo with chicken, broccoli, two slices of garlic bread, and a berry crumble dessert. Interview of Licensed Practical Nurse (LPN) #150 verified the meal served to Resident #28. Interview on 11/01/23 at 1:10 PM with Dietary Manager (DM) #155 revealed staff were trained about therapeutic diets and should be honoring therapeutic and physician ordered diets. Review of the dietary spreadsheet with DM #155 revealed residents on a CCD diet should have received a half portion of garlic bread and a fruit cup instead of the berry crumble dessert. DM #155 was not aware CCD ordered diets should have received a half portion of garlic bread and a fruit cup instead of the berry crumble dessert. DM #155 verified residents on a CCD diet were served full portion sizes of all foods and received the regular dessert instead of the fruit cup indicated on the spreadsheet. Interview on 11/01/23 at 3:00 P.M. with Registered Dietician (RD) #209 verified the lunch meal served did not match the dietary spreadsheet for CCD ordered diets and confirmed facility should be following the resources they had to ensure proper meals were provided. Facility was unable to provide a policy related to providing resident therapeutic diets as ordered. 366042 Page 8 of 9 366042 11/02/2023 Spring Meadows Nursing, A Villa Center 1125 Clarion Ave Holland, OH 43528

F 0800 This deficiency represents non-compliance investigated under Complaint Number OH00147873. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366042 Page 9 of 9