Country Villa LLC

Based on record review, documentation review, and interview, the manager failed to ensure that policies and procedures are implemented to protect and safety of a resident that covered infection control. Findings include: 1. A review of R2's medical record revealed R2 was treated for scabies. 2. A review of the facility's policies and procedures revealed a policy titled "Infection Control." The policy stated, "8. Employees and residents with scabies must be treated with a scabicide [sic] as ordered by the individual's physician and kept away from the residents until 24-hours after the effective therapy. If all residents and employees have experienced significant exposure, every effort should be made to treat each person at approximately the same time. ... 18. All incidents which are ... diagnosed resident infections which could present potential or real harm to individuals in the facility will be documented on the Incident/Accident/Injury Report form." 3. A review of facility documentation did not include incident report forms completed for the aforementioned resident with scabies. 4. In an interview, E1 reported four residents of the facility had been treated for scabies. E1 acknowledged that the facility's policies and procedures, that cover infection control, were not implemented.

Based on record review and interview, the manager failed to ensure that before or at time of acceptance of an individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, for one of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed documentation stating R1 did not require continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner. However, this documentation was not signed within 90 days before or at the time of acceptance. 2. In an interview, E1 acknowledged R1's medical record did not contain documentation signed by a medical practitioner that included if R1 required continuous medical services, continuous or intermittent nursing services, or restraints at the time of acceptance or within 90 days before R1 was accepted into the facility. This is an uncorrected deficiency from the complaint inspection conducted on October 25, 2024.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for two of three residents sampled. The deficient practice posed a risk as false or misleading information was provided to the Department. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's Medication Administration Record (MAR) for December 2024 revealed documentation of administration of the following medications on December 10, 2024 at 8:00 PM: - Clobetasol Cream 0%[sic], thin layer applied topically twice a day (bid); - Tamsulosin 0.4 milligrams (mg), 1 tablet by mouth (po) at bedtime (qhs); and - Ferrous Sulfate 325 mg, 1 tablet po bid. However, MAR documentation was provided for Compliance Officer review at 1:45 PM. 3. A review of R2's MAR for December 2024 revealed documentation of administration of the following medications on December 10, 2024 at 8:00 PM: - Amitriptyline HCl 100 mg, 1 tablet po qhs; and - Docusate Sodium 100 mg, 1 tablet po bid. However, MAR documentation was provided for Compliance Officer review at 1:45 PM. 4. In an interview, E1 acknowledged R1's and R2's medical records did not contain accurate documentation of medication administered to R1 and R2. This is an uncorrected deficiency from the complaint inspection conducted on October 25, 2024.

Based on record review and interview, the manager failed to ensure that a resident was provided a diet that meets the resident's nutritional needs as specified in the resident's service plan, for one of three residents sampled. Findings include: 1. A review of R3's service plan, dated September 24, 2024, indicated R3 did not require a specialized diet. 2. In an interview, E1 reported R3 was provided, and required, a diabetic diet. E1 acknowledged a resident was not provided a diet that meets the resident's nutritional needs as specified in the resident's service plan.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated 90 calendar days before the individual was accepted by the assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner or registered nurse (RN), for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed R1 was accepted by the facility within the last 12 months. 2. A review of R1's medical record revealed a document titled "Admission Orders." This document was signed by a medical practitioner and dated over a month after R1's acceptance by the facility. 3. In an interview, E1 acknowledged R1's medical record did not contain the required documentation that was dated 90 days before R1 was accepted by the facility.

Based on record review, observation, and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for two of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's and R2's medical records revealed R1 and R2 received medication administration. 2. A review of R1's medical record revealed an unsigned medication list for the following medications, dated October 8, 2024: - Amlodipine 10 milligrams (mg), 1 tablet by mouth (po) daily (qd); - Aspirin 81 mg, 1 tablet po qd; - Clopidogrel 75 mg, 1 tablet po qd; - Dicyclomine 10 mg, 1 capsule po twice a day (bid); - Fluoxetine 10 mg, 1 tablet po qd; - Fluticasone Propionate 50 micrograms (mcg), 1 spray in each nostril at bedtime (qhs); - Hydralazine 25 mg, 1 tablet po every 8 hours (q8h); - Hydrochlorothiazide 50 mg, 1 tablet po qd; - Insulin Lispro 100 unit/milliliters (mL), inject subcutaneous three times a day (tid) before meals as per sliding scale; - Lantus Solostar U-100 Insulin 100 unit/mL, Inject 5 units subcutaneously qhs; - Losartan 100 mg, 1 tablet po qd; - Metformin 500 mg, 1 tablet po bid; - Potassium chloride ER 2 Milliequivalent (MEQ), 1 tablet po qd; and - Tamsulosin 0.4 mg, 1 capsule po qhs. However, the medication list was not signed by a medical practitioner as required. 3. A review of R1's medication administration record (MAR) for October 2024 revealed the administration of the following medications: - Amlodipine 10 mg, 1 tablet po qd and indicated 1 tablet was administered at 8:00 AM October 1, 2024 - present; - Aspirin 81 mg, 1 tablet po qd and indicated 1 tablet was at administered at 8:00 AM October 1, 2024 - present; - Clopidogrel 75 mg, 1 tablet po qd and indicated 1 tablet was administered at 8:00 AM October 1, 2024 - present; - Dicyclomine 10 mg, 1 capsule po bid and indicated 1 capsule was administered at 8:00 AM October 1, 2024 - present; - Fluoxetine 10 mg, 1 tablet po qd and indicated 1 tablet was administered at 8:00 AM October 1, 2024 - present; - Fluticasone Propionate 50 mcg, 1 spray in each nostril qhs and indicated 1 spray was administered at 8:00 AM October 1, 2024 - present; - Hydralazine 25 mg, 1 tablet po q8h and indicated 1 tablet was administered at 12:00 AM, 8:00 AM, 4:00 PM October 1, 2024 - present; - Hydrochlorothiazide 50 mg, 1 tablet po qd and indicated 1 tablet was administered at 8:00 AM October 1, 2024 - present; - Insulin Lispro 100 unit/mL, inject subcutaneous tid before meals as per sliding scale and indicated units were administered per sliding scale at 7:00 AM, 11:00 AM, and 4:00 PM October 1, 2024 - present; - Lantus Solostar U-100 Insulin 100 unit/mL, inject 5 units subcutaneously qhs and indicated 5 units were administered at 8:00 PM October 1, 2024 - present; - Losartan 100 mg, 1 tablet po qd and i

Based on record review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of R1's medical record revealed R1 received directed care services. 2. During an environmental tour of the facility, the Compliance Officers observed the front door was equipped with an alarm to alert employees of egress; however, the alarm was not turned on at the time of inspection. The alarm was in working order and was turned on while the Compliance Officers were on-site. 3. The Compliance Officers observed the back door to the facility's patio was not equipped with an alarm to alert employees of egress at the time of the inspection; however, an alarm was added to the door while the Compliance Officers were on-site. 4. In an interview, E1 acknowledged that the facility provided directed care services, and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R2's medical record revealed R2 received medication administration. 2. A review of R2's medication administration record (MAR) for October 2024 revealed documentation that the following medications were administered at 8:00 PM on October 25, 2024: - Clotrimazole 1% ointment; - Eliquis 5 milligrams (mg), 1 tablet by mouth (po); and - Gabapentin 300 mg, 1 capsule po. However, MAR documentation was printed and provided for Compliance Officer review at 11:00 AM. 3. In an interview, E1 acknowledged R2's medical record did not contain accurate documentation of medication administered to the resident.

Based on observation and interview, the manager failed to ensure that foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a container of Welches Grape Jelly open and stored in a non-refrigerated pantry in the kitchen. However, the label of the product stated, "refrigerate after opening." 2. The Compliance Officers observed a container of Great Value Grated Parmesan Cheese open and stored in a non-refrigerated cabinet in the kitchen. However, the label of the product stated, "refrigerate after opening." 3. In an interview, E1 acknowledged the potentially hazardous foods were not maintained at 41\'b0 F or below.

Based on observation and interview, the manager failed to ensure that a rechargeable fire extinguisher was serviced at least once every 12 months. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a rechargeable fire extinguisher that revealed a service date of January 2023. However, no documentation of further service was available. 2. In an interview, E1 acknowledged the facility's rechargeable fire extinguisher was not serviced at least once every 12 months.

Based on observation and interview, the manager failed to ensure that toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed the following toxic materials stored by the facility in an unlocked laundry room, accessible to residents: - Xtra Detergent; - Great Value Disinfectant Spray; - Great Value All Purpose Cleaner with Bleach; - Great Value Glass Cleaner; and - Glade Air Freshener. 2. The Compliance Officers observed a container of Clorox Disinfecting Wipes stored by the facility and placed on the back of a toilet in a shared resident bathroom. 3. The Compliance Officers observed the following toxic materials stored by the facility in a cabinet under the kitchen sink, accessible to residents: - Ajax Dish Soap; - Great Value Dishwasher Gel; and - An unlabeled plastic bag of a white substance. The cabinet was equipped with a lock; however, the lock was not in use at the time of inspection. 4. In an interview, E1 acknowledged the toxic materials stored by the facility were not maintained in labeled containers in a locked area and inaccessible to residents.

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113.A.2.a.i-iii, for one manager, for two caregivers and for one assistant caregiver. The deficient practice posed a TB exposure risk to residents. Findings include: R9-10-113(A)(2)(a)(i)(ii)(iii): ..."a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1) ..." 1. A review of facility documentation revealed an undated policy and procedure titled "Tuberculosis Screening and Risk Assessment." The policy and procedure stated " ...Each individual who is employed by this facility or is providing volunteer services to this facility, or is admitted to this facility, will be required to undergo the following: 1. Conduct TB Risk Assessment upon hire or acceptance ...2. Conduct TB signs/symptoms screening upon date of hire or acceptance ..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E1's (hired in 2023) personnel record revealed documentation of a Mantoux tuberculin skin test dated April 30, 2023. However, a second Mantoux tuberculin skin test was not available for review. 4. A review of E1's personnel record revealed documentation of a baseline screening was not available for review. 5. A review of E2's (hired in 2023) personnel record revealed documentation of a Mantoux tuberculin skin test dated May 15, 2023. However, a second Mantoux tuberculin skin test was not available for review. 6. A review of E3's (hired in 2024) personnel record revealed documentation of a Mantoux tuberculin skin test dated November 30, 2023. However, a second Mantoux tuberculin skin test was not available for review. 7. A review of E4's (hired in 2023) personnel record revealed documentation of a Mantoux tuberculin skin test dated October 20, 2023. However, a second Mantoux tuberculin skin test was not available for review. 8. In a joint interview, E5 and E6 acknowledged E1, E2, E3, and E4 did not provide evidence of freedom from infectious tuberculosis as specif

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: R9-10-113(A)(2)(a)(i)(ii)(iii): ..."a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1) ..." 1. A review of the facility documentation revealed an undated policy and procedure titled "Tuberculosis Screening and Risk Assessment." The policy and procedure stated " ...Each individual who is employed by this facility or is providing volunteer services to this facility, or is admitted to this facility, will be required to undergo the following: 1. Conduct TB Risk Assessment upon hire or acceptance ...2. Conduct TB signs/symptoms screening upon date of hire or acceptance ..." 2. A review of R2's (admitted in 2023) medical record revealed a negative TB skin test. However, a baseline screening was not available for review. 3. In a joint interview, E5 and E6 acknowledged R2 did not provide evidence of freedom from infectious tuberculosis as specified in R9-10-113. Technical assistance was provided on this Rule during the compliance inspection conducted on November 8, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for two of two residents sampled. The deficient practice posed a risk as a resident did not receive the expected service. Findings include: 1. A review of facility documentation revealed a shower schedule. The shower schedule revealed R1 was scheduled to shower on Tuesday's and Thursday's, and R2 was scheduled to shower on Wednesday's and Saturday's. 2. A review of R1's medical record revealed a current service plan for personal care services dated in November 2023. The service plan revealed R1 was to receive assistance with showering two times per week and shaving two times per week. 2. A review of R1's medical record revealed an "Activities of Daily Living" document dated in February 2024. The document indicated R1 received assistance with the following services on the following dates: -February 5, 2024 (shower); and -February 10, 2024 (bed bath). However, documentation R1 received assistance with showering and shaving at least two times per week was not available for review. 3. In an interview, E6 reported R1 was offered showers at least two times per week and would refuse to take showers on some days. 4. A review of R2's medical record revealed a current service plan for directed care services dated in January 2024. The service plan revealed R2 was to receive assistance with showering two times per week and shaving one to two times per week. 5. A review of R2's medical record revealed an "Activities of Daily Living" document dated in February 2024. The document indicated R2 received assistance with showering on February 6, 2024. However, documentation R2 received assistance with showering at least two times per week and assistance with shaving one to two times per week was not available for review. 6. In an interview, E6 reported R2 was offered showers at least two times per week and would refuse to take showers on some days. 7. In a joint interview, E5 and E6 acknowledged R1 and R2 had not received the assisted living service documented in R1's and R2's service plans. This is a repeat deficiency from the on-site complaint investigation conducted on June 1, 2023.

Based on record review and interview, the manager failed to ensure a resident's medical record included the date and time of medication administration, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper medication administration. Findings include: 1. A review of R2's medical record revealed a medication order for Docusate sodium 100 mg capsules, take one capsule two times a day, dated in January 2024. 2. A review of R2's medication administration record (MAR) dated in February 2024 revealed documentation R2 received medication administration of Docusate sodium 100 mg capsules on February 1-13, 2024 at 8AM. However, documentation to indicate R2 received medication administration of Docusate sodium 100 mg capsule two times a day was not available for review. 3. In an interview, E2 reported R2 received medication administration of the above mentioned medication two times a day. E2 reported E2 forgot to document the medication administration and acknowledged the resident's MAR did not include the date and time the medication was administered to R2.

Based on documentation review, record review, and interview, the manager failed to implement policies and procedures to cover medication administration. The deficient practice posed a risk as the standards expected of employees in the policies and procedures were not followed and the Department was unable to determine substantial compliance during the inspection. Findings include: R9-10-101.134. "Medication administration" means restricting a patient's access to the patient's medication and providing the medication to the patient or applying the medication to the patient's body, as ordered by a medical practitioner. 1. A review of facility documentation revealed a policy and procedure titled "Medications" (dated March 1, 2022). The policy and procedure stated "...Each and every time medication is administered to a resident it will be given using the universally accepted '5 Rights' to insure [sic] it is being given as prescribed on the medication order..." 2. A review of Department documentation revealed a complaint submitted in April 2023. The complaint stated "...facility provided patient with another residents medication (Aspirin). Patient is allergic to aspirin. It is on [R3's] records that [R3] is allergic..." 3. A review of R3's medical record revealed an incident report dated in March 2023. The incident report stated "...Mistake...gave a medicine the resident had S.O.B [R3] called [R3's] daughter informed what happened. The daughter called 911." 4. A review of R3's medical record revealed a document titled "RESIDENT FACE SHEET." The document revealed R3 was allergic to "Ibuprofen" and "Aspirin." 5. A review of R3's medical record revealed a medication order (dated in February 2023) for the following medications: -Gabapentin 300 mg -Apixaban 5 mg -Atorvastatin 80 mg -Clopidogrel 75 mg -Escitalopram 10 mg -Levothyroxine 50 mcg -Metoprolol extended release 25 mg -Montelukast 10 mg 6. In an interview, E2 acknowledged the facility failed to implement policies and procedures to cover medication administration.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after a resident's date of acceptance, for one of one discharged resident sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R3's (discharged in 2023) medical record revealed a written service plan with R3's name on it. However, based on R3's admission date a service plan was required. 2. In an interview, E2 acknowledged a written service plan for R3 was not completed within 14 calendar days after acceptance.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of two current residents sampled. The deficient practice posed a risk as a resident did not receive the expected service, the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R1's (admitted in 2023) medical record revealed a current service plan for directed care services dated in February 2023. The plan revealed R1 was to receive the following service: -"Bed Bath 3-4 x week" 2. A review of R1's medical record revealed a document (dated May 2023) titled "ACTIVITIES OF DAILY LIVING." The document revealed R1 received a "Shower" on the following dates: -May 1, 2023; -May 8, 2023; -May 15, 2023; -May 19, 2023; -May 22, 2023; and -May 29, 2023. However, documentation to reveal R1 received a "Bed Bath 3-4 x week" was not available for review. 3. In an interview, E2 reported R1 was bedbound and did not receive showers. 4. In an interview, E2 acknowledged R1 had not received a bed baths per R1's service plan.

Based on record review, documentation review, and interview, the manager failed to ensure a resident's medical record contained the name and signature of the individual administering medication, for one of one discharged resident sampled. The deficient practice posed a risk as the Department was provided false or misleading documentation, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R3's medical record revealed an incident report dated in March 2023. The incident report stated "...Mistake...gave a medicine the resident had S.O.B [R3] called [R3's] daughter informed what happened. The daughter called 911." 2. In an interview, E2 reported E2 was not on shift on March 22, 2023 and E3 was the caregiver working on March 22, 2023 when R3 was given Aspirin. 3. A review of R3's medication administration record (MAR) dated March 2023. The MAR revealed E2 initialed medication administration provided to R3 on March 22, 2023. 4. A review of Department documentation revealed an email received on June 1, 2023 from E5. The email contained a staff schedule dated March 2023. The staff schedule revealed E3 was scheduled to work on March 22, 2023 and not E2. 5. In an interview, the findings were discussed with E2 and E2 stated "I do not remember" why E2 signed R3's MAR when E3 was working.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of two current residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. The Compliance Officer observed Oxybutynin tab 10mg ER, take one tablet by mouth every day for bladder spasm, "Dispensed: 05/28/23" medication bottle belonging to R1. 2. A review of R1's medical record revealed a medication order for Oxybutynin tab 10mg ER was not available for review. 3. In an interview, E2 reported R1 received medication administration of Oxybutynin tab 10mg ER. 4. A review of R1's medication administration record (MAR) dated May 2023 revealed documentation to indicate R1 received medication administration of Oxybutynin tab 10mg ER was not available for review. 5. In an interview, E2 reported E2 forgot to document the medication administration of Oxybutynin tab 10mg ER to R1 in R1's MAR. 6. In an interview, E2 acknowledged medication was administered to R1 without a medication order and not documented in R1's medical record.