Park Senior Villas at Houghton - Villa Gg

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a service plan, dated December 26, 2024, for directed care services. The service plan did not include wound care, document any current skin conditions, and stated R1 did not receive home health services. 2. A review of R1's medical record revealed documentation R1 was on home health services for wound care beginning on January 30, 2025 and had previously been discharged from home health for wound care within the previous 30 days. In a call with the home health agency, it was revealed R1 was on home health from November 18, 2024 to January 9, 2025. 3. The home health assessment and initial plan documented training caregivers on wound care and recognizing symptoms of infection; however, the wound care was ordered to be provided by the RN three times per week. 4. In an interview, E1 acknowledged R1's service plan had not been updated within 14 calendar days after R1 had a significant change in skin condition requiring wound care services.

Based on record review and interview, the manager failed to ensure a resident, receiving directed care services, had a written service plan that was reviewed and updated at least once every three months, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed a service plan for directed care services dated May 15, 2024. Based on the date of R2's service plan, a reviewed and updated service plan was required on or before August 15, 2024. Further review revealed the timeframe for renewal was incorrectly set as annual. 2. In an interview, E1 acknowledged the medical record provided for R2 did not include the required service plan update at least once every three months.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed R2 received medication administration. 2. A review of R2's medical record revealed a signed medication order for "Permethrin 5% External Cream", "Apply a thin layer topically to all reddened rash areas wait 14 hours and wash areas thoroughly, repeat in 7 days, may do a third treatment", dated September 26, 2024. 3. A review of R2's medication administration record (MAR) dated September 2024. The MAR revealed Permethrin was not documented as administered. 4. A review of R2's medication revealed the tube of cream had been opened, however there was no documentation of when or if it was applied or if it was washed off after 14 hours as ordered. 5. In an interview E1 acknowledged the medication administered to R2 was not administered in compliance with a medication order.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed signed medication orders dated September 20, 2024, for "Sertraline 100mg", take one by mouth, "Q HS". 3. A review of R1's medication administration record (MAR) dated September 2024. The MAR revealed Sertraline 100mg, administered at 8am and at 8pm on September 24-30, 2024. 4. A review of R1's medication revealed the medication was correctly labelled and was being administered as ordered, and the MAR was incorrectly documented. 5. In an interview E1 acknowledged the medication administered to a R1 was not accurately documented.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed an unlocked laundry room which was accessible to residents. The Compliance officer observed a can of "AJAX", a can of "Favor" furniture polish, and a bottle of window cleaner unsecured, on the counter. 2. The Compliance Officer observed the caregiver leave a resident room, where the door had been closed, which left the laundry room unattended and accessible to residents. 2. In an interview, E1 acknowledged the toxic materials were unlocked and accessible to residents.