Health inspection·July 7, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on record review, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure Resident #16 who had a indwelling catheter received the appropriate treatment and services related to a urinary tract infection (UTI). This affected one (#16) of six residents reviewed for UTIs. The facility census was 76. Findings include: Review of the medical record for Resident #16 revealed an admission date of 05/01/20 with diagnoses of obstructive and reflux uropathy and type II diabetes mellitus. Resident #16 was admitted to Hospice on 05/25/25. Review of the significant change comprehensive Minimum Data Set (MDS) assessment, dated 05/30/25, revealed Resident #16 had impaired cognition and an indwelling catheter. Review of a urine culture and sensitivity, collected 05/26/25 and reported 05/31/25, revealed Resident #16 had bacterium Acinetobacter baumannii present at greater than 100,000 colony forming units per milliliter. The bacterium was susceptible only to amikacin (an antibiotic). There was nothing in the medical record indicating Resident #16 had symptoms of a UTI and notification to the physician of the results of the urine culture and sensitivity. Review of the current and discontinued physician orders dated 05/31/25 through current revealed no order for amikacin. Interview on 07/07/25 at 1:51 P.M. with Infection Preventionist (IP) #505 confirmed no signs or symptoms were documented in Resident #16's record indicating the purpose of the urinalysis. IP #505 confirmed the identification and testing for a UTI, per McGeer's criteria, required signs and/or symptoms of a UTI must be present before proceeding with a urinalysis. IP #505 confirmed no antibiotics were ordered to treat Resident #16's UTI. Additionally, IP #505 could provide no evidence a physician was notified regarding the results of the urine culture and sensitivity results. Review of facility policy titled Guideline for Infection and Prevention Surveillance Program dated 10/02/19 revealed the facility would have a system for preventing, identifying, reporting, investigating, and controlling infections. Review of the CDC guidance titled NHSN Long-term Care Facility Component Urinary Tract Infection dated January 2025 and found at https://www.cdc.gov/nhsn/ltc/uti/index.html revealed UTI is one of the most common sites of healthcare-associated infections (HAI), accounting up to 20 percent (%) of infections reported by long-term care facilities (LTCFs). There is criteria for catheter-associated symptomatic urinary tract infections (CA-SUTI). This included one or more signs and symptoms and a positive urine culture with no more than two species of microorganisms, at least one of which is a Page 1 of 3 366042 366042 07/07/2025 Spring Meadows Nursing, A Villa Center 1125 Clarion Ave Holland, OH 43528

F 0690 Level of Harm - Minimal harm or potential for actual harm bacterium of 10 CFU/ml or greater. The criteria for asymptomatic bacteremia urinary tract infection (ABUTI) included no qualifying fever or signs or symptoms, a positive urine culture and a positive blood culture with at least one matching bacteria to the urine culture. This deficiency represents non-compliance investigated under Complaint Number OH00166471. Residents Affected - Few 366042 Page 2 of 3 366042 07/07/2025 Spring Meadows Nursing, A Villa Center 1125 Clarion Ave Holland, OH 43528

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, record review and staff and resident interview, the facility failed to ensure medications were administered appropriately and not left unsecured in a resident room. This affected one (#15) of one resident reviewed for medications. The facility census was 76. Findings include: Review of the medical record for Resident #15 revealed an admission date of 5/22/25 with diagnoses of anxiety and enterocolitis (inflammation of the intestines) due to clostridium difficile. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 05/24/25, revealed Resident #15 had intact cognition and rejected care for one-to-three days during the assessment period. Review of the physician order dated 05/21/25 revealed Resident #15 received buspirone hydrochloride (HCl) (for anxiety) 15 milligrams (mg), one tablet three times daily and dicyclomine HCl (for gastrointestinal prophylaxis and cramping) 10 mg one capsule four times daily. Review of the Medication Administration Record for July 2025 revealed Resident #15's prescribed buspirone HCl and dicyclomine HCl were administered as ordered. Observation and interview on 07/07/25 at 4:15 P.M. with Registered Nurse (RN) #201 revealed two medications on Resident #15's floor next to her bed. RN #201 stated the medications were buspirone HCl and dicyclomine HCl. RN #201 stated Resident #15 received the two medications multiple times daily and could not state how long they were on the floor. RN #201 further stated she always stood with Resident #15 until Resident #15 consumed all of her medications. RN #201 confirmed nurses should always remain with residents until all medications are consumed. Resident #15 confirmed RN #201 stayed at her bedside while she consumed her medications. Resident #15 stated she did not know why there were medications on her floor. This was an incidental finding during the complaint survey. 366042 Page 3 of 3