Inspection visit

InspectionJune 13, 2022

VILLA SPRINGFIELD REHABILITATION AND HEALTHCARE CECMS #3658298 citations on this visit

8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include Review of Resident #77's medical record revealed an admission date of 02/06/20. Diagnoses included cognitive communication deficit, failure to thrive and urine retention. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77's cognition was hardly or never understood and required extensive assistance of one staff member for toileting. Observation on 06/06/22 at 10:40 A.M. revealed Resident #77's bathroom appeared dirty, especially the toilet. Resident's toilet had a pink ring in the bowl at the water line and a dark material splattered inside the bowl. Subsequent observations on 06/07/22 at 2:43 P.M., on 06/08/22 at 9:37 A.M., and on 06/08/22 at 11:33 A.M. revealed Resident #77's toilet bowl had a pink discoloration ring around the waterline and had a dark material splattered inside the bowl. On 06/08/22 at 9:37 A.M. and on 06/08/22 at 11:33 A.M., the toilet had urine unflushed sitting in the toilet bowl. Interview on 06/06/22 at 5:42 P.M. with Resident #77's family member revealed concerns about the facility's cleanliness. The family member stated the floors and bathroom had been dirty and she brought in cleaning supplies and scrubbed the bathroom herself due to wanting the resident to have a clean environment. Interview on 06/08/22 at 9:43 A.M. with Housekeeper #22 stated the resident rooms should be cleaned daily including all resident bathrooms. Housekeeper #22 stated there should be three to four housekeeping staff scheduled each day. Interview and observation on 06/08/22 at 2:30 P.M. with Certified Nursing Assistant (CNA) #151 confirmed Resident #77's bathroom was dirty and confirmed the toilet had a pink colored ring at the waterline and dark material splattered inside the bowl. CNA #151 stated Resident #77 was on a toileting training program. CNA #151 stated she would talk with the housekeeping supervisor to make sure Resident #77's bathroom gets cleaned. Review of the facility's undated policy titled Resident Room Cleaning and Bathroom Cleaning revealed the housekeeper should spray disinfectant into the bowl and let it sit for three to five minutes. Staff should wipe the inside of the bowl with cleaning clothes and johnny mops. The policy revealed (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 9 Event ID: 365829 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 365829 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Springfield Rehabilitation and Healthcare Ce 701 Villa Road Springfield, OH 45503 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)

F 0584 a general cleaner can be used for stains as needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365829 If continuation sheet Page 2 of 9 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 365829 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Springfield Rehabilitation and Healthcare Ce 701 Villa Road Springfield, OH 45503 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 03/06/22. Diagnoses included sepsis, pneumonia due to methicillin resistant staphylococcus aureus, chronic obstructive pulmonary disease, heart failure, and atrial fibrillation. Review of the Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had moderate cognitive impairment and was assessed to require two-person total dependence with transfers and one-person extensive assistance with dressing, eating, toileting, and bathing. Review of the care conference records for Resident #71 revealed there were no care conferences held since admission. Interview on 06/08/22 08:54 AM with Social Services Director #13 confirmed there was no admission care conference completed for Resident #71. Social Services Director #13 confirmed Resident #71 did not have a care conference completed while at the facility. 2. Review of the medical record for the Resident #77 revealed an admission date of 02/06/20. Diagnoses included malnutrition, lack of coordination, cognitive communication deficit, aphagia, failure to thrive and urine retention. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77's cognition was hardly or never understood and required extensive assistance of one staff members. Review of the medical record revealed no evidence of care conferences being held since admission. Interview on 06/06/22 at 5:44 P.M. with Resident #77's family member revealed she had not been invited to attend care conferences since the COVID-19 pandemic began. Interview on 06/08/22 at 10:24 A.M. with Director of Social Services #13 revealed facility has no evidence care conferences were completed for Resident #77. Review of the facility's policy titled Care Conference, dated 09/01/21, revealed the facility will hold regular interdisciplinary care conferences to provide residents and families the opportunity to participate in the plan of care. Each discipline shall come prepared to discuss problems, goals, and strategies. Each resident shall be invited to participate in their care conference. At the resident's discretion, the family shall be invited to participate also. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365829 If continuation sheet Page 3 of 9 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 365829 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Springfield Rehabilitation and Healthcare Ce 701 Villa Road Springfield, OH 45503 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)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few Findings include: 1. Review of the medical record for the Resident #11 revealed an admission date of 02/26/21. Diagnoses included COVID-19, malnutrition, hemiplegia and hemiparesis following intracerebral hemorrhage, dementia without behaviors, bipolar disorder, panic disorder, anxiety, and depression. Review of the annual activity assessment dated [DATE] revealed Resident #11 prefers independent and small group activities including watching television, word search, morning group activities, and coffee small group. Review of the care plan dated 02/26/22 revealed Resident #11 was at risk for altered activity patterns and decrease in activity participation with interventions including to provide daily activity listing, allow resident to make choices or decisions, and provide resident with activity calendar. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had significant cognitive impairment and required extensive assistance of one to two staff members for mobility. Observation on 06/06/22 from 1:00 P.M. to 2:30 P.M. of COVID-19 unit revealed no resident activities occurred during this time even though they were scheduled on the calendar. Resident #11 was sitting in his wheelchair at the nursing desk and wandering around in the hallway. Resident #11 stated he was bored. 2. Review of the medical record for the Resident #26 revealed an admission date of 05/25/21. Diagnoses included COVID-19, heart failure, psychosis, dementia without behaviors, and major depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had significant cognitive impairment and required extensive assistance of one to two staff members for mobility. Review of the annual activity assessment dated [DATE] revealed Resident #26 prefers to attend group activities daily and enjoys BINGO and watching television. Review of the care plan dated 04/22/22 revealed Resident #26 planned to stay long term in the facility with interventions to encourage Resident #11 to participate in activities. Observation on 06/06/22 from 1:00 P.M. to 2:30 P.M. of the COVID-19 unit revealed Resident #26 repeatedly came out to the nursing station to her room asking about her rock and needing to take the rock for a walk. Resident was wondering around the unit and was following staff into other resident rooms and interrupted resident care numerous times. Interview on 06/06/22 at 1:25 P.M. with Registered Nurse (RN) #72 revealed the residents on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365829 If continuation sheet Page 4 of 9 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 365829 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Springfield Rehabilitation and Healthcare Ce 701 Villa Road Springfield, OH 45503 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)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few COVID unit have no activities and only have the menu puzzles given to all facility residents. RN #72 revealed activity staff do not provide any assistance with activities while residents reside on the COVID-19 unit. Interview on 06/06/22 at 1:40 P.M. with Certified Nurse Aide (CNA) #80 stated the residents have been getting more disoriented being on the COVID-19 with increased confusion due to limited social interaction, no structure of the day, and isolation away from the rooms they were familiar with. Interview on 06/07/22 at 2:50 P.M. with Activity Director (AD) #19 stated when residents were transferred to the COVID-19 unit, they were given word searches. All facilities residents were given the daily menu packet which also includes coloring pages, sodoku, and crossword puzzles. AD #19 confirmed there were no activities for confused or cognitively impaired residents on the COVID-19 unit. AD #19 stated prior to being transferred to the COVID-19 unit, Resident #11 and #26 would attend group activities. AD #19 stated she used the activity connection website for ideas, but revealed the nurse and aide on the COVID-19 unit do not have the time to sit and read with each resident. AD #19 stated the activity staff had not been going to COVID-19 unit to check on residents and offer activities. Review of the Activity Policies and Procedures, dated 2015, revealed the daily programming should include ongoing activities designed to meet the needs of the residents and follow the interests and the physical, mental and psychological needs for well being of each resident. Create programs for residents who will not or cannot plan their own activities. Activities should offer a range of creative expressions, cultural programs, educational programs, evening programs, exercise and physical programs, helping programs, volunteer and work related programs, humor related programs, music programs, outdoor or outings, pet programs, physical games and recreational activities, recreational explorations, religious or spiritual programs, socials, special needs programs, and welcoming programs. The policy also revealed facility will offer individual and in room visit programs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365829 If continuation sheet Page 5 of 9 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 365829 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Springfield Rehabilitation and Healthcare Ce 701 Villa Road Springfield, OH 45503 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of the medical record for the Resident #29 revealed an admission date of 05/11/20. Diagnoses included unspecified traumatic nondisplaced spondylolisthesis of second cervical vertebra, dementia with behavioral disturbance, and anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had moderate cognitive impairment. Resident #29 required one-person extensive assistance with toileting and supervision with transfers. Review of the progress note dated 05/10/22 at 3:10 P.M. revealed Resident #29 had a fall in the dining room and hit the back of her head. Resident #29 had a hematoma and bruising to back of left arm. Resident #29 refused to go to the hospital. Physician and sister-in-law notified and received new orders for a computed tomography (CT) for the A.M. and hold Eliquis (blood thinner). On 05/10/22 at 8:22 P.M., Resident #29 agreed to be seen at the hospital. Review of the hospital discharge paperwork dated 05/14/22 revealed Resident #29 was admitted for a traumatic nondisplaced spondylolisthesis of C2 vertebral closed fracture after a fall. Review of the progress note dated 05/14/22 at 9:40 P.M. revealed Resident #29 returned from the hospital with a neck brace on, which should be worn at all times. Resident #29 to have a follow-up appointment in six weeks. Review of the physician order dated 05/17/22 revealed Resident #29 was ordered to limit lifting weight bearing to 15 pounds for three months and Resident #29 was ordered a hard cervical collar to be worn at all times. The physician order dated 05/26/22 revealed Resident #29 was ordered an x-ray of cervical spine two or three views on 06/06/22 for a follow up for nondisplaced fracture of C2. Review of the care plan dated 05/30/22 revealed Resident #29 was at risk for falls related to unsteady gait, history of falls, cognition deficits related to dementia, history of self-transfers, unaware of safety awareness, and incontinent of bowel/bladder. Interventions included to apply side rails to bed and hang a 'call before you fall' sign for a visual reminder. Staff to ensure there was a clear pathway. Staff to educate Resident #29 and family to call for assistance before transferring. Staff to keep bed in lowest position. Staff to maintain call light within reach and educate the use of call light. Staff to remind Resident #29 to use call light. Staff to ensure non-skid footwear was in place. Observation on 06/06/22 at 10:52 A.M. of Resident #29's call light revealed it was hanging on the wall behind Resident #29's bed by the privacy curtain and it was not within reach of Resident #29. Resident #29 was lying in bed. Resident #29 stated she does not have a call light. Observation on 06/06/22 at 10:59 A.M. revealed Resident #29 walked to the door with her walker and notified staff that her bed needed changed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365829 If continuation sheet Page 6 of 9 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 365829 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Springfield Rehabilitation and Healthcare Ce 701 Villa Road Springfield, OH 45503 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Observation on 06/07/22 at 9:39 A.M. of Resident #29's call light was hanging on a chair behind Resident #29's bed, which revealed call light was out of reach. Resident #29 was lying in bed at this time. Observation on 06/08/22 at 9:07 A.M. of Resident #29's call light hanging on chair behind bed and privacy curtain revealed call light was out of reach. Resident #29 was lying in bed at this time. Residents Affected - Few Interview on 06/08/22 at 9:11 A.M. with Registered Nurse (RN) #166 confirmed the call light was not within reach of Resident #29. RN #166 wrapped the call light around Resident #29's bed rail in reach of Resident #29. RN #166 educated Resident #29 to use the call light for assistance. Review of the facility's policy titled Falls, revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365829 If continuation sheet Page 7 of 9 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 365829 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Springfield Rehabilitation and Healthcare Ce 701 Villa Road Springfield, OH 45503 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)

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Record review for Resident #5 revealed an admission date of 02/10/22. Diagnoses included toxic encephalopathy, muscle wasting and atrophy, and obstructive and reflux uropathy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact. Resident #5 had an indwelling urinary catheter and was always incontinent of bowel. Review of the hospital records dated 02/10/22 revealed Resident #5 was seen by urology on 01/13/22 and a indwelling catheter was placed. The recommendation was for the indwelling catheter to be removal with voiding trial once having regular bowel movements and more medically stable. The indwelling catheter was removed on 02/08/22 and Resident #5 voided once and was unable to void with recurrent retention. A new indwelling catheter was placed 02/09/22. Resident #5 will be discharged from the hospital with an indwelling catheter. The skilled nursing facility and physician needs to follow and re-attempt a trial of voiding in the future. Review of the Nurse Practitioner (NP) progress notes dated 02/28/22 revealed due to the patient's limited mobility, they will not yet trial removing the catheter, but we will do that as the patient progresses. The NP progress note dated 03/09/22 revealed they will continue to also evaluate the patient's rehabilitative progress to remove her catheter once she was walking more consistently with the walker which she did do today. Review of the medical record from 02/10/22 to 06/08/22 revealed there no documented instance of the removal of the indwelling catheter or a voiding trial. There was no further mention in the medical record in the physician's or NP progress notes about removing the catheter for a voiding trial after 03/09/22. Interview with Resident #5 on 06/06/22 at 11:30 A.M. revealed she was admitted to the hospital a few months ago and they put in an indwelling urinary catheter. She stated the facility did not try to remove her catheter since she has been here. Subsequent interview with Resident #5 on 06/07/22 at 12:50 P.M. revealed she denies having any urinary tract infections since she has been at the facility and stated she ambulates with the assistance of a walker. Interview with the Director of Nursing (DON) on 06/09/22 at 9:10 A.M. stated when a resident has a recently inserted catheter, they send them out for a urologist appointment. The DON verified she could not find anything where the facility attempted a voiding trial or where Resident #5 had a scheduled urologist consult. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365829 If continuation sheet Page 8 of 9 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 365829 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Springfield Rehabilitation and Healthcare Ce 701 Villa Road Springfield, OH 45503 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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. Findings include: Observations on 06/06/22 from 9:05 A.M. to 9:30 A.M. of the initial tour of the kitchen with Dietary Manager (DM) #167 revealed there was a thick layer of dust-like particles noted on the hood and vent above the grill. There were seven out of eleven pans observed were stored on the shelf wet. The sanitation testing strips had expired on 03/01/19, which were being currently used to test the chemical levels of the three-sink sanitation. The dry storage room had seven dented cans which included one can of crushed pineapple, one can of tropical fruit salad, three cans of fruit cocktail, and two cans of mandarin oranges. Interview on 06/06/22 from 9:05 A.M. through 9:30 A.M. with DM #167 verified all findings in the kitchen. Review of the facility's policy titled Food Safety in Receiving and Storage, revealed food is received and stored by methods to minimize contamination and bacterial growth. Food will be inspected when it is delivered to the facility and prior to storage for signs of contamination. Examples of signs of contamination conclude the following: cans with badly swollen sides or ends, flawed seals or seams, rust, dents, or leaks. Contaminated food will be refused and sent back to the vendor for credit. Review of the facility's policy titled Kitchen Sanitation and Cleaning Schedules revealed the facility should ensure a clean and sanitary food environment. The food and dining services manager develops, implements, and monitors a cleaning schedule that assigns specific cleaning responsibilities to specific individuals. The food and dining services manager/designee will check the cleaning schedule at the end of each shift to ensure assignments have been completed. Clean vent hoods to prevent accumulation of dirt and grease. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365829 If continuation sheet Page 9 of 9

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Citations

8 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0222GeneralS&S Fpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0679GeneralS&S Dpotential for harm
F679 - Activities
Provide activities to meet all resident's needs.

FAQ · About this visit

Common questions about this visit

What happened during the June 13, 2022 survey of VILLA SPRINGFIELD REHABILITATION AND HEALTHCARE CE?

This was a inspection survey of VILLA SPRINGFIELD REHABILITATION AND HEALTHCARE CE on June 13, 2022. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at VILLA SPRINGFIELD REHABILITATION AND HEALTHCARE CE on June 13, 2022?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·June 13, 2022