The Villas at Wilmot, Villa B

Based on record review and interview, the manager failed to insure, for one of one sampled residents receiving services from a home health agency, the resident's medical record contained the name, address, and contact individual, including contact information, of the home health agency, any information provided by the home health agency, or a copy of resident follow-up instructions provided to the resident by the home health agency. Findings include: 1. A review of R1's medical record revealed R1 had been admitted in January 2025 from a skilled nursing facility. 2. A review of R1's medical record revealed a document titled, "Provider Approval for Admission," which was signed and dated a few days prior to R1's admission. This document indicated R1 required intermittent nursing services and named the home health agency which would be providing services. 3. A review of R1's medical record revealed documentation of the address, and contact individual, including contact information, of the home health agency, any information provided by the home health agency, or a copy of resident follow-up instructions provided to the resident by the home health agency was not available for review. 4. During the on-site inspection. E1 contacted the home health agency named in the admission form, who reported they had discontinued services in March of 2025. 5. A review of facility progress notes revealed R1 continued to receive weekly home health visits through June 30th, 2025. 6. During the on-site inspection, E1 contacted other home health agencies and determined another home health agency had been providing services to R1 since May, 2025. 7. A review of R1's medical record revealed documentation of the name, address, and contact individual, including contact information, of the current home health agency, any information provided by the current home health agency, or a copy of resident follow-up instructions provided to the resident by the current home health agency were not available for review. 8. A review of R1's current and previous service plans revealed neither service plan included documentation R1 received home health services. 9. In an interview, E1 acknowledged R1's medical record did not include the name, address, and contact individual, including contact information, of each home health agency, any information provided by each home health agency, or a copy of resident follow-up instructions provided to the resident by each home health agency. 10. In an interview, E2 reported the current home health agency had been asked for records and the home health worker told them they would need to order those records from a medical provider. However, documentation of attempts to obtain these records was not provided for review.

Based on record review and interview, when a resident had an injury that resulted in the resident needing medical services, the manager failed to ensure a caregiver immediately notified the resident's emergency contact. Findings include: 1. A review of progress notes for R1 revealed a progress note, dated June 30, 2025 at 5:27 PM, which stated, "resident was observed to not feel well as evidenced by pale in color, scowl, body language drawn, and stating so. resident hurt [themselves] having a bowel movement, as there was blood and [their] sphincter presented a bloody hemorrhoid at the entrance. resident took meds however did not eat meals. PT visited the resident the shift." 2. In an interview, E2 reported they had sent a picture of the injury to R1's doctor, who then came and prescribed something for the injury. E2 had not documented the contact, but showed the Compliance Officer the picture of the injury and the doctor's response on their cell phone, indicating the doctor had been notified. E2 reported they had also notified the emergency contact but was not able to produce any evidence that this had occurred. 3. A review of facility incident reports revealed an incident report had not been generated for the injury. 4. A review of the facility's policy and procedure manual revealed a policy titled, "Quality Management" which stated, "..Upon witnessing or finding an event that threatens the safety, health, and/or welfare of a resident, the employee or volunteer will document the identified event, on the required report form used by the facility. Initial Documentation, after ensuring the safety and well-being of the resident, the employee or volunteer will document the occurrence before the employee or volunteer has finished his/her shift; the appropriate incident report form will be filled out by the employee or volunteer who witnessed or discovered the occurrence..." 5. In an interview, E1 acknowledged, when R1 had an injury which required a medical assessment, the facility had not provided documentation of the immediate notification of R1's emergency contact, and had not completed documentation of the event as required by the facility's policies and procedures.

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented, and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Findings include: 1. A review of E1’s and E2’s personnel records revealed initial and annual training and education related to recognizing the signs and symptoms of tuberculosis was not available for review. 2. A review of E2’s personnel record revealed a baseline screening including a Mantoux skin test, dated January 17, 2024, and a second Mantoux skin test, dated June 13, 2022. However, the June 13, 2022 skin test was dated more than a year prior to E2’s date of hire at the facility and was also dated more than a year prior to the January 17, 2024 test. E2’s personnel record did not contain documentation of a two-step skin test as recommended by R9-10-113.A.1.a 3. A review of R1’s medical record revealed a baseline screening including a Mantoux skin test. However, the skin test result was marked "pending’ and did not include documentation of whether the test result was negative or positive. 4. A review of R2’s medical record revealed three Mantoux skin tests, each marked negative. However, R2’s medical record did not include a baseline screening questionnaire to include an assessment of R2’s risks of prior exposure to infectious tuberculosis and a determination if R2 had signs or symptoms of tuberculosis. 5. In an interview, E1 acknowledged the health care institution had not documented, and implemented tuberculosis infection control activities as required in R9-10-113.A.2.a-f. Technical assistance was provided during the on-site compliance inspection conducted on February 1, 2024.

Based on interview, observation, and record review, the manager failed to ensure a resident's written service plan included an accurate description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for two of two residents sampled. Findings include: 1. A review of R1’s medical record revealed a service plan, updated February 6, 2025, for personal care services. The service plan stated, “Medical Diagnosis / Health Problems: atrial fibrillation, open wounds, foley, GERD, CKD, Gout, CHF, amputated.” However, in the skin care section of the service plan, the service plan stated, “Basic skin care to help prevent bruising, skin tears and decubitus ulcers…Do skin checks with each shower, report any redness, bruises or changes to manager, check for dry skin daily and moisturize if [R1’s] skin is dry, check fingernails on shower days to make sure they are short, clean and smooth.” In the section for home health, the service plan stated, “Nurse visits three times a week for wound care.” 2. In an interview, E4 reported R1 did not have any open wounds remaining at the time of the inspection, and reported the description of R1’s medical or health problems of having open wounds was not accurate. 3. A review of R2's medical record revealed a service plan, dated November 11, 2024, for Directed care services. The service plan listed the following diagnoses: "Schizoaffective Disorder, Bipolar, Neurocognitive Disorder." The service plan stated R2’s diet was “as tolerated.” However, under the section for food intake, the service plan stated, “Special Needs: Avoid products with gluten due to Celiac Disease.” 4. A review of R2’s medical record revealed a document titled, “Diagnosis and Doctor’s orders,” signed and dated by a medical practitioner at the time of R2’s admission. The document included a list of medical diagnosis, including, “Celiac disease.” The document asked if the resident can eat a regular diet, and R2’s doctor had checked, “other” and wrote, “Diabetic diet recommended." Under allergies, R2's doctor listed Statins and Sulfa drugs, and did not list gluten. 5. A review of R2's medical record revealed a service plan, dated November 11, 2024, for Directed care services. The service plan stated, “Fasting blood sugar checked at each meal, Use sliding scale (Novolog) as ordered.” 6. A review of R2’s medical record revealed orders for scheduled Lantus insulin twice daily, and one blood sugar check per day. 7. In an interview, E4 reported R2 no longer uses sliding scale insulin, and they would need to clarify with R2’s primary care physician if a gluten free diet is required as the service plan states. 8. In an interview, E1 acknowledged R1’s and R2's service plans did not accurately describe each resident’s medical or health problems to include their physical, behavioral, cognitive, or functional conditions or impairments.

Based on record review, documentation review, observation, and interview the manager failed to ensure a resident is treated with dignity, respect, and consideration. The deficient practice posed a risk if a resident was subjected to ridicule, demeaning, or derogatory remarks. Findings include: 1. A review of facility documentation revealed an incident report, dated, April 9, 2024, marked "Late Entry", with an incident date of April 6, 2024. The incident report stated, "While [E6] was assisting other members change, [E5] was in office giving meds while [E6] went to laundry room. [E6] was trying to get [R2] into [R2's] room by shoving and kneeling (sic) [R2] in the back, [R2] was heard shouting prior to this, stating "He" was hurting [R2]. When [E6] went to living room, [R2] was no longer there. After assisting other members, [R2] was back in the living room, staff utilized Hoyer and assisted [R2] back into room after meds were provided. [E6] checked all back, no injuries seen......IR Late entry - Management notified 4/9/24, family and APS notified 4/9/24, internal investigation started 4/10/24." 2. A review of facility documentation revealed an internal investigation dated April 9, 2024 through April 12, 2024. The investigation included the following allegations residents had not been treated with dignity, respect, and consideration: -" ...[E6] reported that [E5] was physically and verbally abusive towards [R2]. Yelling, cussing, and kneeing [R2] in the back while [R2] was on the floor because [R2] refused to get up during the night shift 7pm-7am 4/6/24"; -"..[E6] explained that [R2] does not sleep when [E5] is working because [R2] is afraid of [E5]. [E6] stated that [E5] picks on 5 of the residents in the villa." -"...[E6] stated that [E5] yells at [R2] and tells [R2] to go to [R2's] room and sleep, [R2] needs to stay in [R2's] room. [R2] puts [themselves] on the floor often as part of [R2's] behavior....[R2] was on the floor scooting around the house yelling for [E6], [E6] came out and [E5] was kneeing [R2] in the back while [R2] was on the floor screaming for [E6] because [E5] was hurting [R2], and [E5] started to drag [R2] back into [R2's] room from the kitchen.." -"...[E5] was verbally abusive towards [R3] and yelled at [R3] to shut and just go to [R3's] room and sleep..."; -"...[E6] reported [E5] would mock [R4] and would make fun of [R4]. [R4] would sundown and thinks that the villas is "[R4's] house" during [R4's] episodes, [E5] would yell at [R4], "This is my house, I am married to your daughter, and I am the boss here! I tell you what to do," then would laugh at [R4] just to get [R4] more confused and upset..."; -"..[E6] stated that [E6] witnessed [E5] yelling at [R1], " Get out of there get back to your room now." When [R1] would not listen to [E5], [E6] would start to push/shove [R2] making [R2[ go into [R2's] bedroom"; and -"...[E6] reported that [E5] becomes agitated and upset when [R5] comes out for snacks during the shift and start

Based on observation, record review, 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 residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated November 8, 2023, for directed care services including medication administration. 2. A review of R2's medical record revealed a signed list of orders, dated August 15, 2023, which included the order, "Novolog Flexpen U-100 Insulin 100 unit/mL (3 mL) insulin pen, inject 5 unit subcutaneously three time a day, dose depending on FBS results, Check FBS three times a day with meals and use the Novolog sliding scale - for diabetes." 3. A review of R2's medical record revealed an electronic Medication Administration Record (eMAR) dated January 2024. The eMAR documented the medications administered to R2 including, "Novolog Flexpen Syringe: Check fasting blood sugar 3 times daily at meals and use the Novolog sliding scale." However, the eMAR included multiple dates where the dosage of insulin provided to R2 had not been documented. 4. In an interview, E1, E2, and E3 acknowledged the eMAR did not fully document the medication administered to R2 to include the sliding scale dosage of insulin provided at each meal.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of the facility work schedule revealed the facility worked on two shifts per day, a 7 AM to 7 PM (day )shift and a 7 PM to 7 AM (night) shift. 2. A review of facility disaster drills conducted during the previous twelve months revealed documentation of the following drills: - September 2023, no day noted, on the day shift; - June 11, 2023, on the day shift; - June 15, 2023, also on the day shift; - March 24, 2023, on the day shift; and - March 14, 2023, also on the day shift. 3. In an interview, E1, E2, and E3 acknowledged the provided documentation of disaster drills did not include documentation of disaster drills conducted on each shift at least once every three months.