Spring Meadows Nursing, A Villa Center

Penalty

Inspection fine: $49,445

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Resident #55, who was admitted with diagnoses including metabolic encephalopathy, epilepsy, right-sided hemiplegia, and type II diabetes mellitus, was dependent on staff for all transfers and bed mobility, was always incontinent of bowel and bladder, and was assessed as being at high risk for pressure wounds. The admission MDS indicated he did not have a pressure ulcer on admission and there were no skin or ulcer/injury treatments in place, including a turning and reposition program. The care plan addressed skin integrity risk, incontinence care, barrier cream, a pressure reduction mattress, and a wheelchair pressure reduction cushion, but it did not include turning and repositioning every two hours or routine checks and changes for incontinence care. Weekly skin observations initially showed no new skin issues, but a later skin assessment identified a new stage three pressure wound to the left buttock and coccyx. Wound measurements showed the wound increased in size from 3.20 cm by 2.50 cm by 0.10 cm on 08/05/25 to 5.0 cm by 4.5 cm by 0.2 cm on 08/21/25. Staff interviews confirmed Resident #55 was immobile, at risk for pressure ulcers, and did not have the intervention of turning and repositioning every two hours in place, and the DON confirmed that this standard of practice was not documented in the care plan or in the record.

Penalty

Inspection fine: $49,445

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Food was served in a manner that did not prevent contamination during room tray service and lunch preparation. During breakfast tray delivery on the 400-hall, CNA #306 began passing trays without performing hand hygiene, delivered trays to multiple residents, and repeatedly handled trays, resident rooms, bedding, lights, bed controls, and resident food items without washing his hands between residents. He opened milk, arranged beverages, removed lids from food containers, added brown sugar to oatmeal, stirred oatmeal with a resident’s silverware, cut up food with tray silverware, and later entered the soiled workroom and another resident’s room before returning to feed a resident, all without hand hygiene. CNA #306 confirmed during interview that he did not perform hand hygiene throughout the observed tray service. During lunch service, [NAME] #374 touched pan lids, steam table surfaces, serving utensils, plates, spatulas, and a frying pan handle, then touched a grilled cheese sandwich with the same contaminated gloved hand before placing it on a plate for service. Regional Food Services Director #500 stated the sandwich should not have been touched with contaminated gloved hands. In a separate observation, Dietary Aides #372 and #391 returned to the tray line and put on clean gloves without washing their hands. The facility policy required hand hygiene before and after resident care, before assisting with meals, and hand washing before putting on gloves and after handling soiled utensils and equipment.

Penalty

Inspection fine: $49,445

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents’ care needs for two residents reviewed. For Resident #27, the medical record showed an admission date of 07/11/25 with diagnoses including chronic respiratory failure with hypoxia, COPD, and obstructive sleep apnea. Hospital referral records dated 07/11/25 included BIPAP orders to continue at night and during naps with inspiratory pressure of nine and expiratory pressure of five, but physician orders for 07/11/25 to 07/13/25 did not include an order for a BIPAP machine. The admission MDS assessment indicated the resident was cognitively intact and did not use a BIPAP machine. Observation on 08/25/25 showed Resident #27 had a BIPAP sitting on the nightstand, and on 08/26/25 the resident was observed resting in bed with the BIPAP on and stated she used BIPAP at home and had brought her machine to the facility. An LPN confirmed the resident required BIPAP use in the facility and that the admission MDS should have reflected it. For Resident #2, the record showed diagnoses of multiple sclerosis and paraplegia, and the care plan included interventions for bowel and bladder incontinence. The annual MDS stated the resident was frequently incontinent of bowel and bladder, while the quarterly MDS stated the resident was always continent; the DON and an LPN both verified the resident was always incontinent of bowel and bladder, and the LPN confirmed the MDS assessments contained incorrect continence data.

Penalty

Inspection fine: $49,445

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to regularly monitor Resident #55’s weight according to physician orders and facility policy. The resident was admitted with diagnoses including metabolic encephalopathy, gastroesophageal reflux disease, and type II diabetes mellitus. Physician orders dated 07/10/25 directed staff to obtain an admission weight, then weekly weights for four weeks, and then monthly weights. The medical record showed a weight of 225 pounds on 07/10/25 and a later weight of 180.6 pounds on 08/04/25, with no other weights documented in the record. This reflected a 19.7% weight loss over 24 days. During interview, LPN #401 confirmed the resident’s weights were not obtained according to physician orders or facility policy and stated the significant weight variance should have resulted in a reweigh to confirm the variance. The facility policy titled Weight Monitoring Guideline required residents to be weighed on admission, weekly for four weeks post-admission, then monthly, and stated that a weight variance of less than or greater than five pounds would require a reweigh.

Penalty

Inspection fine: $49,445

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain physician orders for oxygen therapy and BIPAP use for one resident (#27) reviewed for respiratory care. The resident was admitted on 07/11/25 with diagnoses including chronic respiratory failure with hypoxia, COPD, and obstructive sleep apnea. Hospital referral records from the admission date showed orders to continue BIPAP at night and during naps with inspiratory pressure of nine and expiratory pressure of five, along with oxygen therapy at two to four liters per minute. The admission assessment also documented that the resident was admitted via wheelchair and oxygen by nasal cannula. Review of the current physician orders for 08/2025 showed no orders for either BIPAP use or oxygen administration. On 08/25/25, the resident was observed lying in bed with the BIPAP sitting on the nightstand. An LPN verified on 08/26/25 that there were no physician orders for oxygen therapy and BIPAP machine use for the resident. Another LPN later verified on 08/28/25 that she updated the physician orders to include oxygen therapy and BIPAP use. Facility policies for oxygen administration and CPAP/BIPAP support both required review of the physician's orders for oxygen and BIPAP settings and use.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with an indwelling catheter and diagnoses including obstructive and reflux uropathy and type II diabetes mellitus did not receive appropriate treatment and services related to a urinary tract infection (UTI). The resident was admitted to hospice and had impaired cognition. A urine culture collected showed the presence of Acinetobacter baumannii at a significant level, with susceptibility only to amikacin. Despite these findings, there was no documentation in the medical record of UTI symptoms, no evidence that the physician was notified of the urine culture and sensitivity results, and no order for the indicated antibiotic was found. An interview with the Infection Preventionist confirmed that there were no documented signs or symptoms of a UTI and that, according to McGeer's criteria, such symptoms are required before proceeding with urinalysis. The Infection Preventionist also confirmed that no antibiotics were ordered and that there was no evidence of physician notification regarding the positive urine culture. Facility policy and CDC guidance require systems for infection prevention, identification, and reporting, but these were not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that medications prescribed to a resident with anxiety and enterocolitis were found unsecured on the floor next to the resident's bed. The medications identified were buspirone hydrochloride and dicyclomine hydrochloride, both of which were ordered to be administered multiple times daily. The registered nurse present confirmed that she typically remained with the resident until all medications were consumed, but could not explain how long the medications had been left on the floor or why they were not secured. The resident also confirmed that the nurse usually stayed with her during medication administration and was unaware of why the medications were on the floor. The medical record review indicated that the resident had intact cognition and a history of rejecting care on some days. Despite this, the facility failed to ensure that medications were administered appropriately and not left unsecured in the resident's room, as required by professional standards and facility policy. This incident was identified during a complaint survey and affected one resident out of those reviewed for medication administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate portions of food to residents, as observed during a meal service. Staff member [NAME] #301 served chili, cornbread, salad, and pumpkin pie for the noon meal, but used a serving spoon instead of a spoodle utensil to measure portions, resulting in insufficient servings for residents on regular and mechanical soft diets. The Dietary Manager (DM) #503 confirmed that the facility did not prepare enough chili to meet the required 8-ounce portion for these diets. Additionally, residents on a pureed diet received only 1 and 5/8 ounces of chili and cornbread, instead of the required 8 ounces of chili and 3 ounces of cornbread. Furthermore, the facility did not provide all menu items to residents on a pureed diet. Observations revealed that residents on a pureed diet were served only chili and cornbread, with no vegetable or dessert as per the menu. Instead of a vegetable, applesauce was provided, and gelatin dessert was given instead of pumpkin pie due to the pie being too frozen to serve. Interviews with staff confirmed these discrepancies, and it was noted that Resident #24 did not receive the complete meal as outlined in the menu, lacking both a vegetable and dessert. This deficiency was investigated under Complaint Number OH00163287.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriately textured food for residents on specialized diets, specifically those on mechanical soft and pureed diets. Observations and interviews revealed that residents on a mechanical soft diet received the same chili and cornbread as those on a regular diet, despite the menu indicating they should receive ground beef and bean chili. The Dietary Manager confirmed that whole kidney beans were used in the chili for both regular and mechanical soft diets, and there was no specific recipe for the mechanical soft version of the chili. Additionally, the facility did not adhere to dietary orders for residents requiring thickened liquids. One resident on a pureed diet with honey-thick liquids was given regular vanilla ice cream, which melts into a thin liquid, contrary to their dietary needs. Another resident on a pureed diet with nectar-thick liquids received a meal tray that included unthickened lemonade and gelatin dessert, both inappropriate for their dietary restrictions. These deficiencies were identified during a complaint investigation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper hand hygiene and food handling practices during meal service, as observed during a noon meal preparation. A staff member, identified as [NAME] #301, was seen wearing disposable gloves while opening a refrigerator and handling a bag of shredded lettuce without changing gloves after touching the exterior of the bag. This staff member also failed to wash hands between glove changes and did not change gloves after retrieving a slice of cheese from the cooler before preparing a cheeseburger. These actions were confirmed through interviews with the staff member. Additionally, the facility did not cover food during delivery to resident rooms. Observations revealed that pumpkin pie served to residents was not covered, both on the tray cart and during distribution to resident rooms. Dietary Aide #302 was observed setting a resident's meal tray on the ground to add a salad, which was confirmed through an interview. The facility's policies on food preparation, hand washing, and meal distribution were reviewed, indicating that staff should avoid contamination and cover food during transport, which was not adhered to in these instances.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely access to medical records for two residents, affecting their legal representatives' ability to obtain necessary documentation. For Resident #12, who had impaired cognition and was discharged to another long-term care facility, the son requested copies of medical records via email. Despite the request being forwarded to the medical records department, the records were not provided to the son. Instead, the records request form was mistakenly sent to another individual, and a medical records release form was sent to the resident's email address. The medical records were not provided to the son by the time of the interview with the medical records staff. For Resident #72, who had intact cognition and diagnoses of Parkinson's disease and type II diabetes mellitus, the healthcare Power of Attorney (POA) requested medical records for a court hearing. Despite submitting the necessary release forms, the request was not processed in a timely manner. The medical records staff initially prepared the records but was informed that the request needed to be processed through the corporate office. The request, initiated in November, was not forwarded to the corporate office until January, well past the requested deadline. The facility's policy required a 48-hour notice for obtaining records, which was not adhered to in these cases.

Penalty

Inspection fine: $13,627

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement immediate action to protect residents from Legionella bacteria after a water sample test detected Legionella on the 300 Hall. Despite being aware of the positive test result on 06/03/24, the facility only stopped the use of water on the 300 Hall and did not take further interventions for other areas. This inaction resulted in Immediate Jeopardy when a resident on the 100 Hall developed respiratory symptoms and was later diagnosed with Legionella pneumonia on 06/14/24. The resident, who had multiple sclerosis with paraplegia and other health conditions, experienced a decline in health, including respiratory symptoms, and was transferred to the hospital. The hospital diagnosed the resident with Legionella pneumonia, sepsis with acute renal failure, and septic shock. The facility was notified of the positive Legionella result on 06/16/24 but failed to notify the local health department or implement immediate protective measures for the remaining residents. Interviews and reviews revealed that the facility had low chlorine levels in the water system and did not take corrective actions. The facility's water management plan required reporting Legionella cases to health officials and conducting investigations, but these steps were not followed. The facility's failure to act promptly and notify the appropriate authorities placed all residents at risk of exposure to Legionella bacteria.

Removal Plan

• An additional 10 water samples were taken for legionella testing. Results for the 10 samples were received and each tested negative for Legionella bacteria.
• Maintenance Services Director (MSD) #301 will audit the recirculating pipe one time daily for two months to ensure appropriate temperatures are maintained.
• MSD #301 set the facility's circulating pump to continuous run.
• MSD #301 installed filtered shower heads on all showers.
• The DON will audit staff call-offs three times weekly for four weeks for signs and symptoms related to Legionella illness.
• Regional Director of Operations (RDO) #320 and Regional Director of Plant Operations (RDPO) #325 reviewed the facility's water management policy and updated it to meet the Centers for Disease Control (CDC) and the Ohio Department of Health's (ODH) recommendations.
• The Administrator re-educated MSD #301 and Maintenance Assistant (MA) #330 on flushing the whole water system utilizing the flushing documentation log and testing and documenting chlorine levels daily to ensure adequate sanitization to kill Legionella and to validate electronic measuring systems.
• Dietary Manager (DM) #306 inventoried the in-house bottled water and confirmed a sufficient supply was available to meet resident needs.
• Food Service Provider (FSP) #500 delivered bagged, bulk ice. Deliveries will continue two times weekly (Mondays and Thursdays) and as needed until the facility's water is deemed safe by the LHD.
• MSD #301 installed a medical grade ice machine filter (protects against Legionella) on the facility's ice machine. The refrigeration contractor serviced the medical grade ice machine filter for use.
• ADON #300 began all staff education on the facility's Legionnaires Guidelines, to include no use of facility faucets, bed pan washers, ice machine, kitchen faucets/sprayers or any other water source; nebulizer, CPAP, Bi-Pap and respiratory equipment to be rinsed with sterile water; proper use of alcohol-based hand sanitizer for residents and staff and utilizing bottled water for hand washing if hands are visibly soiled; and use of bottled water for drinking, brushing teeth and cleaning. Any staff, including agency staff, unable to be reached will receive the education from ADON #300 or designee prior to their next scheduled shift.
• MSD #301 covered all faucets, ice machine and all other water supply sources to ensure no resident or staff use.
• An Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held to review the facility's Legionella Policy and Procedures and the steps taken to remediate the immediacy of the concern. A root cause analysis was initiated to determine gaps in monitoring the Water Management System to prevent Legionella outbreaks and implement corrective actions in conjunction with the local health department (LHD).
• The DON completed a respiratory assessment on all residents with no new respiratory concerns identified.
• The DON or designee will complete respiratory monitoring on all residents each shift until the results of the final water samples are received and the facility water is deemed safe by the LHD.
• Corporate Medical Director (CMD) #650 audited all residents sent to the hospital in the past 30 days for potential Legionella related illness. No areas of concern related to Legionella illness were identified.
• MSD #301 will audit water chlorine levels, water temperatures and flushing of dead legs two times weekly for two months. Any concerns will immediately be reported to the Administrator and follow up with the QAPI committee to determine appropriate interventions.
• The Administrator or designee will complete audits of three random staff three times weekly for four weeks then one time monthly for two months to ensure compliance with the Legionella education provided.
• The QAPI Committee will meet monthly to review audit results to ensure on-going compliance. An Ad Hoc QAPI will be held to address any immediate audit findings.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure medications were kept secure at all times, affecting one resident observed for medication storage. Resident #17, who was cognitively intact and had multiple diagnoses including acute bronchiolitis, pulmonary embolism, and type II diabetes mellitus, was found with a medication cup containing several pills left unattended on the over bed table. This observation was made on 05/02/24 at 8:00 A.M., and it was confirmed by the Assistant Director of Nursing that medications are not to be left at the bedside and that nurses are required to observe residents taking all medications provided. Interviews with RN #101 and Resident #17 revealed that medications were sometimes left at the bedside, contrary to the facility's policy. The facility's policy, titled 'General Standards for Medication Administration,' states that medications are to be administered at the time they are prepared and not left unattended if open. This deficiency was investigated under Master Complaint Number OH00153054 and Complaint Number OH00152502.