Inspection·May 2, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, medical record review, resident and staff interview, and review of facility policies, the facility failed to ensure medications were kept secure at all times. This affected one (#17) of three residents observed for medication storage. The facility census was 85. Findings include: Review of the medical record for Resident #17 revealed an admission date of 03/15/24. Diagnoses included acute bronchiolitis due to respiratory syncytial virus, pulmonary embolism, acute respiratory failure, type II diabetes mellitus, protein calorie malnutrition, chronic kidney disease, atrial fibrillation, heart failure, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 03/22/24, revealed Resident #17 was cognitively intact. Review of the current physician orders revealed Resident #17 was ordered the diuretic Bumex one (1) milligram (mg) two tablets by mouth, the supplement cholecalciferol 125 micrograms (mcg) by mouth, the supplement ferrous sulfate 325 mg by mouth, the supplement magnesium oxide 400 mg by mouth, the antidepressant Zoloft 50 mg with instructions to give one and one-half tablets to equal 75 mg by mouth, the anticoagulant apixaban five (5) mg by mouth, the blood pressure medication Coreg 12.5 mg by mouth, the acid reducer 20 mg by mouth, the stool softener sennosides-docusate sodium 8.6-50 mg by mouth, and the phosphorus-lowering medication sevelamer carbonate 800 mg by mouth all ordered for morning administration. Review of Resident #17's May 2024 medication administration record (MAR) on 05/02/24 at 8:01 A.M. revealed the morning medications had been signed off as administered. Interview on 05/02/24 at 7:51 A.M. with Registered Nurse (RN) #101 verified she has found resident medications at the bedside. RN #101 stated when medications are found, RN #101 told the other nurses they cannot leave medications at the bedside. Observation on 05/02/24 at 8:00 A.M. of Resident #17's room revealed a medication cup with several pills inside on the over bed table sitting in front of Resident #17. Resident #17 was awake and sitting upright in bed with no nurse in the room or vicinity. Interview on 05/02/24 at 8:03 A.M. with the Assistant Director of Nursing confirmed medications are not to be left at bedside and the nurses were to observe residents taking all medications provided. (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 2 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 05/02/2024 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)