VillaSpring of Erlanger

In the surveyor’s words

From the most serious findings on record at VillaSpring of Erlanger, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 11, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF880Sep 11, 2025

  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. […]

• No harm, potential for more than minimal, patternF880Oct 11, 2024

  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… […]

• No harm, potential for more than minimal, patternF755Apr 8, 2021

  Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have safeguards and systems in place to control, account for, and reconcile controlled medications to ensure all controlled medications were maintained for two (2) of sixteen (16) sampled residents (Resident #15 and Resident #16). Resident #16 was prescribed [MEDICATION NAME]/APAP 5/325 milligram (mg) tablet (a controlled, Schedule II, narcotic pain medication), to be administered one (1) tablet every four (4) hours PRN (as needed) for severe pain. The Pharmacy documented delivery to the facility of twenty (20) tablets or one (1) skid of the medication, on 10/23/2020 at 12:51 AM, with a signed receipt by Licensed Practical Nurse (LPN) #5. […]

• No harm, potential for more than minimal, patternF880Jan 27, 2021

  Based on observation, interview, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment; to prevent and/or contain COVID-19; and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observations of multiple staff from the Environmental Services Department revealed hand hygiene was not performed correctly and masks were either not being worn or being worn incorrectly, with the nose left uncovered. […]