Inspection·March 20, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few Findings included: Review of the medical record for Resident #27 revealed an admission date of 12/18/23 with medical diagnoses of unspecified cord compression, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, and recent left femur fracture. Review of the medical record for Resident #27 revealed a Minimum Data Set (MDS) assessment, dated 12/25/23 which indicated Resident #27 was cognitively intact and required maximum staff assistance for bathing bed mobility, toileting and transfers and required supervision with eating. Review of the MDS revealed no documentation to support Resident #27 had a pressure ulcer upon admission to the facility. Review of the medical record for Resident #27 revealed a significant change in condition assessment, dated 02/09/24, which stated an open area to the buttock was noted. The assessment stated the Nurse Practitioner was notified. The assessment did not include a description, measurements or staging of the open area to the buttock. Further review of the medical record revealed no documentation of the description, measurement or staging of the open area on 02/09/24. Review of the medical record for Resident #27 revealed a wound evaluation, dated 02/14/24, which indicated Resident #27 had a Stage III pressure ulcer to her sacrum which measured 5.0 centimeters (cm) by 4.0 cm by 0.1 cm with 50% slough noted. The evaluation stated the pressure ulcer was acquired in the facility and a new treatment was ordered. The evaluation stated the pressure ulcer was unavoidable secondary to resident's overall decline in health. Further review of the medical record revealed a wound evaluation, dated 03/13/24, which indicated Resident #27's sacrum pressure ulcer had deteriorated with measurements of 7.0 cm by 8.0 cm x 0.1 cm with 50% slough. Review of the medical record for Resident #27 revealed physician orders dated 01/06/24 to apply silver sulfadiazine cream 1% to buttocks every shift and as needed. Review of the medical record revealed physician orders dated 02/14/24 to apply silver sulfadiazine cream 1%, then barrier cream and an abdominal pad to the sacrum ulcer two times per day and as needed, low air loss mattress, and Prostat 30 milligrams for wound healing. Review of the treatment administration records (TAR) and medication administration records (MAR) for January 2024, February 2024, and March 2024 revealed treatments were completed as ordered and medication was administered as ordered. (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: 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 03/20/2024 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)