Inspection Reports for Villa Springfield Rehabilitation and Healthcare Center
701 Villa Rd, Springfield, OH 45503, United States, OH, 45503
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
93 residents
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 93
Deficiencies: 11
Feb 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, medication management, nutrition, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to timely notify physicians of significant weight loss in residents, delayed development of baseline care plans, incomplete care conferences, inadequate provision of scheduled showers, improper storage of insulin vials, failure to serve nutritional supplements appropriately, incomplete meal intake documentation, improper food storage practices, failure to track employee illness call-offs, and failure to notify residents' representatives of COVID-19 outbreaks.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure timely notification to physicians of significant weight loss for residents #31 and #48. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to create baseline care plans within 48 hours of admission for residents #15 and #53. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct required care conferences for residents #15, #20, #31, #33, and #51. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide scheduled showers as required for Resident #15. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to adequately monitor weights and implement timely interventions for residents #31 and #48 with significant weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure insulin vials were stored properly for residents #09, #186, #188, and #191. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nutritional supplements were served in a manner appropriate for consumption for Resident #48. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored in a manner to prevent potential spread of foodborne illness affecting multiple food items in refrigerators and freezers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain adequate documentation of meal intakes for residents #20, #31, and #48. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to track employee call offs related to personal illness and failed to ensure annual TB screenings were completed for seven employees. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify residents' representatives and/or families of COVID-19 outbreak status in a timely manner. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 93
Weight loss percentage: 13.7
Weight loss percentage: 21
Number of residents reviewed for baseline care plans: 11
Number of residents reviewed for care conferences: 19
Number of residents on supplements: 37
Number of employees reviewed for TB screening: 7
Number of residents receiving insulin: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #211 | Nurse Practitioner | Interviewed regarding lack of notification of significant weight loss for residents #31 and #48 |
| Registered Dietician #210 | Registered Dietician | Interviewed regarding weight monitoring and notification responsibilities |
| Social Service Director #105 | Social Service Director | Interviewed regarding baseline care plans and care conferences |
| Director of Nursing | Director of Nursing | Interviewed regarding shower schedules, meal intake documentation, and TB screening |
| Certified Nursing Assistant #181 | Certified Nursing Assistant | Reported frozen nutritional supplements for Resident #48 |
| Human Resource Manager #127 | Human Resource Manager | Interviewed regarding lack of tracking employee illness call offs |
| Administrator | Administrator | Interviewed regarding COVID-19 outbreak notification procedures and employee illness tracking |
| Registered Nurse #192 | Registered Nurse | Interviewed regarding insulin storage |
| Licensed Practical Nurse #131 | Licensed Practical Nurse | Interviewed regarding food storage and labeling |
| Licensed Practical Nurse #136 | Licensed Practical Nurse | Employee file reviewed for TB screening documentation |
| Licensed Practical Nurse #137 | Licensed Practical Nurse | Employee file reviewed for TB screening documentation |
| Licensed Practical Nurse #154 | Licensed Practical Nurse | Employee file reviewed for TB screening documentation |
| Certified Nursing Assistant #153 | Certified Nursing Assistant | Employee file reviewed for TB screening documentation |
| Certified Nursing Assistant #173 | Certified Nursing Assistant | Employee file reviewed for TB screening documentation |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Mar 20, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to complete an assessment of a pressure ulcer upon discovery.
Findings
The facility failed to complete a proper assessment of a pressure ulcer for Resident #27, including lack of description, measurement, and staging of the wound upon discovery. Treatments and medications were administered as ordered, but documentation was incomplete.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00151656.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to complete an assessment of a pressure ulcer upon discovery for Resident #27, including no description, measurements, or staging of the open area on 02/09/24. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Census: 79
Pressure ulcer measurements: 5
Pressure ulcer measurements: 7
Medication dosage: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #124 | Licensed Practical Nurse (LPN) | Completed the change of condition assessment on 02/09/24 and confirmed lack of measurement and description of the wound |
| Director of Nursing | Director of Nursing (DON) | Confirmed medical record did not contain measurement or description of the wound on 02/09/24 |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Feb 27, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to treat a resident with dignity and respect when the Administrator threatened to discharge the resident.
Findings
The facility failed to treat Resident #55 with dignity and respect, as the Administrator threatened to discharge the resident to a homeless shelter due to behavioral issues. Interviews and record reviews confirmed the threat and inappropriate handling of the situation, despite limited documented behavioral incidents.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00150051.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights when the Administrator threatened to discharge a resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 3
Facility Census: 74
Incident Documentation: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CA #250 | Corporate Administrator | Contacted by Resident #75's family regarding concerns about Administrator's threat to discharge Resident #55; apologized and offered assistance |
| LPN #210 | Licensed Practical Nurse | Reported no knowledge of Resident #55's behaviors and that behavioral tracking was not being done |
| Administrator | Threatened to discharge Resident #55 to a homeless shelter and admitted to using the threat to scare the resident | |
| Director of Nursing | Director of Nursing (DON) | Unable to find evidence of recent behaviors leading to discharge discussion or 30-day notice |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 1
Dec 21, 2023
Visit Reason
The inspection was conducted due to a complaint investigation (Complaint Number OH00148733) regarding the facility's failure to ensure medications were administered per physician orders upon admission.
Findings
The facility failed to administer medications as ordered to five residents (#29, #32, #110, #111, and #112) upon admission, as confirmed by medical record reviews, medication administration records, staff interviews, and policy review. The Director of Nursing acknowledged the issues and described ongoing education efforts for nursing staff.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00148733.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure medications were given per physician orders upon admission affecting five residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 5
Facility census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and verified medication administration failures; described education efforts for nursing staff. |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Feb 3, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication administration errors, specifically the failure to administer intravenous antibiotics in a timely manner.
Findings
The facility failed to ensure intravenous antibiotics were administered timely to one resident (Resident #84) out of three reviewed. The nurse responsible did not document or report the missed medication dose, and no explanation was provided in the progress notes.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH 00139675.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure intravenous antibiotics were administered in a timely manner to Resident #84. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 97
Residents reviewed for IV antibiotics: 3
Resident affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #166 | Nurse who did not administer the Daptomycin and did not document or report the missed dose |
Inspection Report
Census: 81
Deficiencies: 6
Jun 13, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, environment, activities, fall prevention, catheter care, and food safety at Villa Springfield Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to maintain cleanliness of resident bathrooms, lack of timely care conferences, inadequate activities on the COVID-19 unit, failure to implement fall prevention interventions, failure to timely assess and attempt voiding trials for residents with indwelling catheters, and unsafe food storage practices in the kitchen.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain cleanliness of a resident's bathroom, including dirty toilet bowls with pink rings and unflushed urine. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely care conferences for residents and/or family, affecting two residents reviewed for care planning. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide activities to residents on the COVID-19 unit, resulting in boredom and increased disorientation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure fall interventions were in place for a resident with a history of fall with major injury, including call light not within reach. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely assess and attempt voiding trial for a resident with an indwelling urinary catheter. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safe storage of equipment and foods in the kitchen, including dust on hood vents, wet pans stored on shelves, expired sanitation testing strips, and dented canned goods. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 81
Facility census: 81
Number of pans wet on shelf: 7
Number of dented cans: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director #13 | Social Services Director | Confirmed no admission care conferences completed for Resident #71 and Resident #77 |
| Certified Nursing Assistant #151 | Certified Nursing Assistant | Confirmed Resident #77's bathroom was dirty and discussed toileting training program |
| Housekeeper #22 | Housekeeper | Stated resident rooms and bathrooms should be cleaned daily |
| Registered Nurse #72 | Registered Nurse | Reported no activities provided on COVID-19 unit |
| Certified Nurse Aide #80 | Certified Nurse Aide | Reported residents on COVID-19 unit were more disoriented due to isolation and lack of activities |
| Activity Director #19 | Activity Director | Confirmed no activities for cognitively impaired residents on COVID-19 unit and lack of staff support |
| Registered Nurse #166 | Registered Nurse | Confirmed call light was not within reach of Resident #29 and repositioned it |
| Director of Nursing | Director of Nursing | Verified no documented voiding trial or urologist consult for Resident #5 |
| Dietary Manager #167 | Dietary Manager | Verified kitchen deficiencies including dust, wet pans, expired sanitation strips, and dented cans |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 20, 2019
Visit Reason
The document is a statement of deficiencies and plan of correction for Villa Springfield Rehabilitation and Healthcare Center, summarizing the findings of the annual survey completed on 2019-06-20.
Findings
No health deficiencies were found during the inspection.
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