VillaSpring of Erlanger

Based on observation, interview, and facility policy review, the facility failed to prepare food in accordance with professional standards for food safety. This had the potential to affect 131 of 132 current residents that received food from the kitchen.The findings include:Review of the facility's policy titled, Uniform - Dress Code, revised 01/2024, revealed hair and beard nets must be worn by kitchen staff.1. Observation on 09/09/2025 at 9:28 AM revealed Food Service Worker (FSW) 1 had both sides of her hair, approximately three inches, not contained in the hairnet.During an immediate interview with FSW1 at the time of the observation she stated she received education involving how to wear hairnets and all hair was to be covered.2. Observation on 09/09/2025 at 9:47 AM revealed the Executive Chef had her front bangs, approximately two inches, not contained in the hairnet.During an immediate interview with the Executive Chef at the time of the observation she stated the facility policy was all hair should be covered. She stated her front bangs were not covered because she was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the facility's policies, and review of the Centers for Disease Control and Prevention (CDC) guidlines related to enhanced-barrier precautions (EBP) and transmission-based precautions (TBP), the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases for 4 out of 27 sampled residents (Residents (R) 5, R20, R65, and R86) 1. Observation on 09/09/2025 revealed the Medical Records Supervisor failed to remove her gloves or perform hand hygiene before leaving a resident's room after handling trash and walked through the hallway with gloved hands and opened the dirty utility room door with contaminated personal protective equipment (PPE).2. Observation on 09/09/2025 revealed State Registered Nurse Aide (SRNA) 3 entered room [ROOM NUMBER], an EBP room, then exited the room without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 27 sampled residents (Resident (R) 2 and R20).Observation during lunch service on 09/09/2025 revealed the Occupational Therapy Assistant (OTA) was standing between R2 and R20 while assisting them with eating lunch.Additional observation during lunch service on 09/09/2025 revealed the Nurse Practitioner (NP) approached R20, who was seated at a table eating lunch with R20, to obtain vital signs from the resident while she was eating. The findings include:Review of facility policy titled, Resident Rights, undated, revealed the resident shall be treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs. 1. Review of R2's admission Record revealed the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to establish a system of records of receipts and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and failed to determine drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 out of 27 sampled residents (Resident (R) 101). Review of the Controlled Drug Receipt Record/Disposition Form for the 2100 Hall medication cart on 09/11/2025 revealed an incorrect count for R101's pregabalin 50 milligram (mg) capsules.Review of the Narcotic Shift Count sheet for the 2200 Hall medication cart on 09/11/2025 revealed Licensed Practical Nurse (LPN) 4 failed to sign the Narcotic Shift Count sheet as the oncoming nurse. Review of the Narcotic Shift Count sheet for the 2100 Hall medication cart on 09/11/2025 revealed LPN3 failed to sign the Narcotic Shift Count sheet as the oncoming nurse. The findings include:Review of the facility's policy titled Controlled Drug Reconciliation, revised 06/2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to label and store medications in accordance with currently accepted professional principles for 2 out 27 sampled residents (Resident (R) 94 and R103).During an observation of the 1300 Hall medication cart on 09/11/2025, a medicine cup containing R94's opened medications was found in the drawer. The medications were documented as given.During an observation of the 2100 Hall medication cart on 09/11/2025, a medicine cup containing R103's opened medications was found in the drawer. The medications were documented as given. The findings include:Review of the facility's policy titled, Administration Oral Medication, revised 11/2024, revealed the facility ensured residents were given medications per the physician's orders. The policy stated medications are given at the time ordered.Review of the facility's policy titled, Medication Storage, revised 04/2024, revealed medications and biologicals for each resident are stored in the containers in which they were originally received.1.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, review of the manufacturer's instructions for use, and review of the facility's policies, the facility failed to maintain infection prevention and control measures to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents sampled for transmission- based precautions (Resident (R) 36 and R107) and 1 of 3 residents reviewed for use of sit-to-stand mechanical lifts (R21). The findings include: Review of the facility's policy titled, Infection Control: Transmission Based Precautions, dated 9/2024, revealed the facility was to implement contact precautions for residents known or suspected to be infected with microorganisms that could be transmitted by direct or indirect contact with the resident or the resident's environment. Further review revealed infections indicating use of contact precautions included multi-drug resistant organisms. Per the policy, staff was to wear gloves and gown for interactions that involved contact with the resident. Review of the facility's policy titled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility policy, it was determined the facility failed to prepare and serve food under sanitary conditions. Observation on 08/14/19 of the second floor Unit 2 dining room, revealed Dietary Aide #5 held four (4) saucer plates against her clothing and put her ungloved thumb and other fingers into the middle and over the rim of the saucers prior to placing the saucers into the middle of the table. In addition, observation on 08/14/19, revealed Dietary Staff #4 was wearing gloves while talking on a cell phone and did not wash hands and change gloves after putting the phone away and prior to continuing to work in the kitchenette. Furthermore, observation of the second floor kitchenette on 08/14/19, revealed Dietary Aide #1 was working during tray service from 5:08 PM to 6:15 PM, without wearing a beard net to cover his beard. Dietary #1 was also observed to use gloved hands to pull up and readjust his scrub top; however, failed to wash hands and don new gloves prior to continuing to work in the kitchenette. The findings include: Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, it was determined the facility failed to ensure the accuracy and completion of Section K of the Minimum Data Set (MDS) Assessment, for one (1) of twenty-five (25) sampled residents (Resident #94). Review of Resident #94's Quarterly MDS Assessment, dated 06/19/19, Section K0300, revealed the facility assessed the resident as not having a weight loss of ten percent (10%) or more in the last six (6) months; however, record review of the resident's weights revealed the resident sustained an 18% weight loss during the 180 day look back period between 12/06/19 and 06/04/19. In addition, review of Resident #94's Significant Change MDS Assessment, dated 07/17/19, Section K0300, revealed the facility assessed the resident as not having a weight loss of ten percent (10%) or more in the last six (6) months; however, record review of the resident's weights revealed the resident sustained a 15.50 % weight loss during the 180 day look back period…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as is possible. Observation on 08/13/19 and 08/14/19, revealed an opened tube of Ammonium Lactate Cream 12% ( moisturizer for dry itchy skin) and an opened tube of Remedy Antifungal Cream 2% (Miconazole Nitrate) on the bedside table in Resident #46's room accessible to residents and visitors. In addition, staff interviews revealed Resident #17 was confused and ambulatory and wandered into and out of resident rooms. The findings include: Review of the facility's Medication Storage Policy, dated 08/2018, revealed medications and biologicals, including treatment items, are securely stored in a secured locked cabinet/cart or locked medication room that is inaccessible to residents and visitors. Review of Resident #46's clinical revealed the facility admitted the resident on 05/23/19 with diagnosis to include Major Depression, Chronic Pain, Type 2 Diabetes, and Dementia. Review of Resident #13's Annual Minimum Data Set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined the facility failed to ensure drug irregularities reported by Pharmacy were acted on for one (1) of twenty-five (25) sampled residents (Resident #94). Resident #94 was prescribed Lorazepam (antianxiety medication) PRN (as needed) on 03/18/19 with no end date; however, there was no documented rationale for extending the medication beyond fourteen (14) days nor was there documentation stating the duration for the PRN order. On 04/19/19, the Physician responded to the Consultation Report from Pharmacy documenting the duration was indefinite and the rationale was hospice patient. On 06/03/19, the Consultation Report from the Pharmacist Consultant stated the SOM (State Operations Manual) required a duration of therapy even for hospice patients and indefinite was not allowed per CMS (Centers for Medicare and Medicaid) guidelines. However, there was no indication of the Physician's choice to either accept, decline, or modify the recommendations. This Report was not signed or dated by the Physician and there was no documented evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined the facility failed to ensure PRN (as needed) orders for psychotropic drugs were limited to fourteen (14) days, unless the Physician documents the rationale for extending the order and documents the duration of the PRN order for one (1) of twenty-five (25) sampled residents (Resident #94). Resident #94 was prescribed Lorazepam (antianxiety medication) PRN on 03/18/19 with no end date; however, there was no documented evidence of the rationale for extending the medication beyond fourteen (14) days nor was there documented evidence of the duration for the PRN order. On 04/19/19, the Physician responded to the Consultation Report from Pharmacy stating the duration was indefinite and the rationale was hospice patient. However, indefinite was not an acceptable duration for the PRN order. There was no further duration for the medication documented after subsequent requests from pharmacy. The Physician's Order for the PRN Lorazepam continued until 08/07/19. (Refer to F-756) The findings include: Review of the facility's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals for one (1) of twenty-five (25) sampled residents (Resident #46). Observation on 08/13/19 and 08/14/19, revealed Resident #46 had an opened tube of Ammonium Lactate Cream 12% ( moisturizer for dry itchy skin) and an opened tube of Remedy Antifungal Cream 2% (Miconazole Nitrate) on the bedside table in his/her room. The findings include: Review of the facility's Medication Storage Policy, dated 08/2018, revealed medications and biologicals including treatment items are securely stored in a secured locked cabinet/cart or locked medication room that is inaccessible to residents and visitors. Review of Resident #46's medical record revealed the facility admitted the resident on 05/23/19 with diagnoses to include Major Depression, Chronic Pain, Type 2 Diabetes, and Dementia. The facility assessed Resident #13, in an Annual Minimum Data Set (MDS) Assessment, dated 05/10/19, as having a Brief Interview for Mental Status (BIMS) of a thirteen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.