The Villas at Wilmot, Villa C

Based on record review and interview, the manager failed to ensure, for one of two sampled residents, a medication administered to a resident was administered in compliance with a medication order. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed a service plan, dated June 9, 2025, for personal care services including medication administration. 2. A review of R2's medical record revealed a list of medication orders, dated September 5, 2025, which included an order for "Losartan Potassium 25 MG TA, Daily at 8:00 AM / 1 TABS, Take 1 tablet by mouth daily for blood pressure, if below 120/70 HOLD." 3. A review of R2's medical record revealed a medication administration record (MAR) dated November 2025. The MAR documented the administration of Losartan to R2 on each day in November 2025. However, the MAR documented the following days and times when Losartan had not been administered as ordered: On November 6, 2025 at 8:33 AM, R2's blood pressure was documented to have been 117/77. However, Losartan had been marked as administered; On November 17, 2025 at 9:06 AM, R2's blood pressure was documented more than an hour after the scheduled time of administration and was documented to have been 117/62. However, Losartan had been marked as administered; On November 18, 2025 at 8:52 AM, R2's blood pressure was documented to have been 124/62. However, Losartan had been marked as administered; and On November 19, 2025 at 9:03 AM, R2's blood pressure was documented more than an hour after the scheduled time of administration and was documented to have been 117/62. However, Losartan had been marked as administered. 4. In an interview with E1, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site compliance inspection conducted on November 25, 2024.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed a service plan, updated October 10, 2024, for directed care services including medication administration. 2. A review of R2's medical record revealed an order, dated July 23, 2024, for "Oxymetazoline HCI (Nasal Spray) 0.05% Nasal Solution, Give 2 sprays in each nostril BID." 3. A review of R2's medical record revealed an electronic Medication Administration Record (eMAR) dated October 2024. The eMAR documented the following: - The eMAR did not document the administration of Oxymetazoline to R2; and - The eMAR indicated, "Fluticasone Prop 50 MCG SPR, Use 2 sprays in each nostril twice daily," had been administered to R2 twice each day in October 2024. 4. A review of R2's medical record revealed an order for Fluticasone was not available for review. 5. The Compliance Officer observed R2's medications included a box of Fluticasone. However, Oxymetazoline was not available for administration. 6. In an interview, during the on-site inspection E1 contacted R2's pharmacy to send the order for Fluticasone. 7. A review of an order sent by R2's pharmacy during the on-site inspection revealed an order, dated July 23, 2024, for, "Nasal Spray 0.05% Nasal Solution, Give 2 sprays in each nostril BID." 8. Online research into, "Nasal Spray 0.05% Nasal Solution," provided only results for Oxymetazoline on "WebMD," "Mayoclinic.org," "Medlineplus.gov," "Drugs.com," and "dailymed.nlm.nih.gov. (National Institutes of Health)." 9. In an interview, E1 acknowledged R2 had been administered Fluticasone instead of Oxymetazoline. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on November 20, 2023.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed three unsecured oxygen containers in the laundry room. 2. In an interview, E1 acknowledged the oxygen containers were not secured. E1 immediately placed the oxygen containers in a box to secure them in an upright position.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored 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 a facility tour, the Compliance Officer observed a residents room did not have a lock on the door and the resident was not present during the inspection. On a shelf in the resident's bathroom, the Compliance Officers observed a container of isoproplyl alcohol. 2. In an interview, E1 and E2 acknowledged poisonous or toxic materials were not stored in a locked area and inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on January 19, 2023, and the on-site compliance inspection conducted on November 20, 2023.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During a facility tour, the Compliance Officer observed a door located at the end of a hallway between bedrooms. The door was equipped with a door alarm; however, the alarm did not sound when the door was opened. The Compliance Officer observed the door alarm had been turned off. 3. In an interview, E1 and E2 acknowledged a means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility did not control or alert employees of the egress of a resident from the facility.

Based on observation, record review, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk as administered medication could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed a service plan, updated September 2, 2023, for personal care services including medication administration. 2. A review of R1's medical record revealed a signed list of medication orders, signed October 23, 2023, which included an order for, "Midodrine HCI 10 MG Oral tablet, give 1 tap PO QID - hold for systolic B/P > 120, start 1/20/23." 3. A review of R1's medical record revealed an electronic Medication Administration Record (eMAR) dated November 2023. The eMAR documented the medications administered to R1 and documented R1's systolic blood pressure as follows: - On November 4, 2023 at 8:25 a..m, R1's blood pressure was 123/74, however, R1's Midodrine was not held as ordered; - On November 6, 2023, at 7:50 a.m., R1's blood pressure was 123/71, however, R1's Midodrine was not held as ordered; - On November 6, 2023 at 12:19 p.m., R1's blood pressure was 122/86, however, R1's Midodrine was not held as ordered; - On November 7, 2023 at 9:10 p.m., R1's blood pressure was 123/98, however, R1's Midodrine was not held as ordered; - On November 9, 2023, at 11:11 p.m., R1's blood pressure was 154/96, however, R1's Midodrine was not held as ordered; - On November 10, 2023 at 11:11 p.m., R1's blood pressure was 148/92, however, R1's Midodrine was not held as ordered; - On November 10, 2023 at 8:00 p.m., R1's blood pressure was 148.92, however, R1's Midodrine was not held as ordered; - On November 11, 2023 at 2:07 a.m., R1's blood pressure was 136/09, however, R1's Midodrine was not held as ordered; - On November 11, 2023 at 8:28 p.m., R1's blood pressure was 130/81, however, R1's Midodrine was not held as ordered; - On November 12, 2023 at 8:20 p.m., R1's blood pressure was 123/89, however, R1's Midodrine was not held as ordered; - On November 13, 2023 at 8:38 p.m., R1's blood pressure was 123/88, however, R1's Midodrine was not held as ordered; - On November 14, 2023 at 8:18 p.m., R1's blood pressure was 123/76, however, R1's Midodrine was not held as ordered; - On November 16, 2023, at 8:01 p.m, R1's blood pressure was 122/68, however, R1's Midodrine was not held as ordered; - On November 17, 2023 at 8:51 p.m., R1's blood pressure was 127/81, however, R1's Midodrine was not held as ordered; and - On November 20, 2023 at 8:58 a.m., R1's blood pressure was 123/72, however, R1's Midodrine was not held as ordered. 4. In an interview, E1 and E2 acknowledged R1's eMAR indicated Midodrine had not been administered in compliance with a medication order. This is a repeat deficiency from the on-site complaint inspection conducted on January 19, 2023.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored 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 a facility tour, the Compliance Officer observed a closet located in a hallway was used to store hygiene items for each resident. The closet had a lock but the closet had been left unlocked and unattended. Inside the closet, the Compliance Officer observed a container of "nail polish remover." 2. In an interview, E1 and E2 acknowledged poisonous or toxic materials were not stored in a locked area and inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on January 19, 2023.