Spring Meadows Nursing, A Villa Center

In the surveyor’s words

From the most serious findings on record at Spring Meadows Nursing, A Villa Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880Jul 1, 2024

  Based on observation, medical record review, staff interviews, interviews with the Local Health Department (LHD), review of hospital medical records, review of water sample testing reports, review of chlorine level logs, review of the facility's water management plan and review of the facility's water treatment program, the facility failed to implement immediate action to protect residents from Legionella (bacteria that causes a severe form of pneumonia with exposure generally from droplets of water) when a water sample test detected Legionella on the 300 Hall on 06/03/24. […]

• Actual harm, isolatedF686Aug 28, 2025

  Based on medical record review, staff interviews, review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and review of facility policy, the facility failed to timely identify the resident's pressure until it reached an advanced stage and failed to ensure pressure ulcer preventions consistent with professional standards of practice were in place. This resulted in Actual Harm to Resident #55 who was at risk for pressure ulcers and the facility found Resident #55's avoidable pressure ulcer as a stage three pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed). This affected one (Resident #55) of two residents reviewed for pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF563Nov 4, 2021

  Based on review of medical record, family and staff interview, review of facility correspondence, and policy review, the facility failed to allow residents to have visitation by family members at any time. This affected one (#55) resident who's family was interviewed and had the potential to affect all 81 residents residing in the facility. Findings include: Review of Resident #55's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's quarterly Minimum Data Set (MDS) assessment, dated 09/30/21, revealed the resident had a low cognitive function. Review of Resident #55's most recent care plan revealed her leisure preferences included having visitors. Interview with Resident #55's family on 11/01/21 at 3:15 P.M. […]

• No harm, potential for more than minimal, patternF812Aug 28, 2025

  Based on observations, staff interviews, and review of facility policies, the facility failed to serve food in a manner that prevented contamination. This affected seven (Residents #13, #19, #35, #45, #54, #86, and #87) observed for room tray service and had the potential to affect all residents in the facility except Residents #4, #9, #12, and #88 who do not receive food from the kitchen. The facility census was 80. Findings include:1. Observation on 08/26/25 at 8:05 A.M. of tray service on the 400-hall revealed Certified Nurse Assistant (CNA) #306 began passing breakfast trays and did not perform hand hygiene before he started. CNA #306 began with serving a breakfast tray to Resident #86 by setting the tray on her bedside table in her room. […]

• No harm, potential for more than minimal, patternF803Mar 13, 2025

  Based on observation, staff interview, and review of the menu spreadsheet, revealed the facility failed to provide adequate portions of food. Additionally, the facility failed to ensure adequate food was prepared to provide all residents with an appropriate portion of food. This had the potential to affect all residents in the facility except Resident #92 who received no food by mouth. Finally, the facility failed to ensure residents on a pureed diet received all items on the menu. This affected five (#13, #24, #39, #42, and #94) residents on a pureed diet. The facility census was 90. Findings include: 1. Observations and interviews on 03/12/25 beginning at 11:37 A.M. revealed [NAME] #301 serving the noon meal. [NAME] #301 stated the meal was chili, cornbread, salad, and pumpkin pie. […]