Villa Springfield Rehabilitation and Healthcare Ce

Inspectors wroteBased on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure medications were administered according to physician orders. This affected three (Resident #15, #9, #93) out of four residents reviewed for medication administration. Additionally, the facility failed to ensure medications prescribed were not borrowed and administered to other residents. This affected one (Resident #9) out of three residents reviewed for medication use. The facility census was 90. Findings Included:1. Medical record review for resident #15 revealed an admission date on 5/27/26. Diagnosis included fracture of Right humorous type two diabetes and hyperlipidemia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to prevent the potential spread of foodborne illness. This had the potential to affect 91 of 93 residents in the facility. The facility identified two Residents (#44 and #52) who did not receive food from the facility. The facility census was 93.

Inspectors wroteBased on observation, staff interview, record review, employee file review, and facility policy review, the facility failed to track employee call offs related to personal illness as part of the facility surveillance program for infectious diseases. This had the potential to affect all 93 residents who resided in the facility. The facility also failed to ensure annual employee Tuberculosis (TB) screenings were completed. This affected seven employees (Housekeeping Supervisor #103, Licensed Practical Nurses [LPNs] #136, 137 and #154, Certified Nursing Assistants [CNA] #153 and #173, and [NAME] #190) of the seven employee files reviewed but had the potential to affect all residents. The facility census was 93.

Inspectors wroteBased on record review, staff interview, review of online guidance from Centers for Medicare and Medicaid Services (CMS), the facility failed to notify the resident's representatives and /or families of the facility's Coronavirus 2019 (COVID-19) status during an outbreak. This had the potential to affect all residents at the facility. The facility census was 93.

Inspectors wroteBased on medical record reviews, staff interviews, and policy review, the facility failed to conduct care conferences as required. This affected five residents (#15, #20, #31, #33, and #51) of the 19 residents reviewed for care conferences. The facility census was 93.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure insulin vials were stored properly. This affected four Residents (#09, #186, #188, and #191) who received insulin. The facility identified nine residents received insulin. The facility census was 93.

Inspectors wroteBased on review of the medical record, staff interviews, and policy review, the facility failed to ensure the resident's physician and/or provider was notified timely when residents developed significant weight loss. This affected two Residents (#31 and #48) of the twelve residents reviewed for significant weight loss. The facility census was 93.

Inspectors wroteBased on medical record reviews, staff interviews, and policy review, the facility failed to ensure baseline care plans were developed within 48 hours of admission. This affected two Residents (#15 and #53) of the 11 residents reviewed for baseline care plans. The facility census was 93.

Inspectors wroteBased on medical record review, staff and resident interviews, and policy review, the facility failed to ensure showers were provided as scheduled. This affected one Resident (#15) of the four residents reviewed for showers/baths. The facility census was 93.

Inspectors wroteBased on review of the medical record, staff interviews, and policy review, the facility failed to adequately monitor weights and implement appropriate interventions in a timely manner. This affected two Residents (#31 and #48) of the twelve residents reviewed for significant weight loss. The facility census was 93.

Inspectors wroteBased on review of the medical record, staff interviews, observations, and policy review, the facility failed to ensure supplements were served in a manner appropriate for consumption. This affected one Resident (#48) of the 37 residents on supplements. The facility census was 93.

Inspectors wroteBased on review of the medical record and interviews, the facility failed to maintain adequate documentation of meal intakes. This affected three Residents (#20, #31, and #48) of the nineteen residents reviewed for documentation. The facility census was 93.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to complete an assessment of a pressure ulcer upon discovery. This affected one (#27) out of three residents reviewed for pressure ulcers. The facility census was 79.

Inspectors wroteBased on staff interview, resident interview, resident representative interview, and medical record review, the facility failed to treat a resident with dignity and respect when the Administrator threatened to discharge a resident. This affected one (Resident #55) of three reviewed for abuse. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview interview, and policy review, the facility failed to ensure medications were given per physician orders upon admission. This affected five (#29, #32, #110, #111, and #112) of five residents reviewed for medications. The facility census was 93.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure storage of equipment and foods were kept in a safe manner. This had the potential to affect all 81 residents residing in the facility who received meals from the kitchen.

Inspectors wroteBased on medical record review, family interview, staff interview, review of the facility's policy, and observation, the facility failed to maintain the cleanliness of a resident's bathrooms. This affected one (Resident #77) of 24 residents reviewed for physical environment. The facility census was 81.

Inspectors wroteBased on record review, family interview, staff interviews, and policy review, the facility failed to provide the residents and/or family with timely care conferences. This affected two (#71 and #77) of two residents reviewed for care planning. The facility census was 81.

Inspectors wroteBased on staff interviews, record reviews, review of the facility's policy, and observations, the facility failed to provide activities to the residents on the COVID-19 unit. This affected two (Residents #11 and #26) of 15 residents residing on the COVID-19 unit. The facility census was 81.

Inspectors wroteBased on observations, record review, staff interviews, and policy review, the facility failed to ensure fall interventions were in place for a resident with a history of fall with a major injury. This affected one (Resident #29) of two residents reviewed for falls. The facility census was 81.

Inspectors wroteBased on resident interview, staff interview, hospital record review, and medical record review, the facility failed to ensure a resident admitted with an indwelling urinary catheter was timely assessed for the removal of the catheter as soon as possible and did not attempt a voiding trial. This affected one (Resident #5) of two residents reviewed for indwelling urinary catheters. The facility identified five residents with indwelling urinary catheters. The facility census was 81.