The Villas at Wilmot, Villa E

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents sampled who received medication administration. Findings include: 1. A review of R2's medical record revealed a service plan, dated August 20, 2024, for directed care services including medication administration. 2. A review of R2's medical record revealed an order, dated August 22, 2024, for, "Humira (2 pen) 40 MG/ 0.8ML Subcutaneous Pen-injector Kit, inject 40 mg subcutaneously every 14 days." 3. A review of R2's medical record revealed an electronic Medication Administration Record (eMAR) dated September 2024. The MAR documented the medications administered to R2 during the month of September, 2024. However, the eMAR documented the following: - On September 21, 2024, "Humira 40 MG / 0.8 ML PEN, Inject 0.8 ML (40MG) Subcutaneously Once Every 14 Days," had been marked, "Med Not available"; - On September 22, 2024, "Humira 40 MG / 0.8 ML PEN, Inject 0.8 ML (40MG) Subcutaneously Once Every 14 Days," had been marked, "waiting on pharmacy"; - On September 23, 2024, "Humira 40 MG / 0.8 ML PEN, Inject 0.8 ML (40MG) Subcutaneously Once Every 14 Days," had been marked, "waiting on pharmacy"; - On September 24, 2024, "Humira 40 MG / 0.8 ML PEN, Inject 0.8 ML (40MG) Subcutaneously Once Every 14 Days," had been marked as administered; - On September 25, 2024, "Humira 40 MG / 0.8 ML PEN, Inject 0.8 ML (40MG) Subcutaneously Once Every 14 Days," had been marked, "Refused"; - On September 26, 2024, "Humira 40 MG / 0.8 ML PEN, Inject 0.8 ML (40MG) Subcutaneously Once Every 14 Days," had been marked as administered; and - On September 27, 2024, "Humira 40 MG / 0.8 ML PEN, Inject 0.8 ML (40MG) Subcutaneously Once Every 14 Days," had been marked as administered. 4. In an interview, E1 acknowledged the eMAR provided for R2 did not accurately document the medications administered to R2. E1 reported only two doses of Humira were provided by the pharmacy.

Based on record review and interview, the manger failed to ensure, for one of two residents sampled, each resident had a written service plan which included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments or the amount, type, and frequency of assisted living services being provided to the resident. Findings include: 1. A review of R1's medical record revealed a service plan dated February 14, 2024. The service plan listed some diagnoses including left-sided hemiplegia/Hemiparesis, however, the service plan did not describe a specific impairment related to R1's left wrist, include physical therapy services, or include the type, amount, and frequency of a splint required by R1. 2. A review of R1's medical record revealed an order dated February 27, 2024 which stated, "Left Wrist hand splint, to be worn daily and PT/OT to determine any further wear schedule to be implemented by the caregivers. 3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated April 2024. The MAR included documentation of the following service: - "Left wrist hand splint, to be worn daily and removed at night," was provided at 8 AM and 8 PM on each day in April 2024. 4. In an interview, E1 acknowledged R1's service plan had not been updated to add the splint services.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated February 14, 2024, for personal care services. The service plan included a list of services which would be provided to R1 each day. 2. A review of R1's medical record revealed a document titled, "Caregiver ADL Checklist," (ADL) dated April 2024, which documented the services provided to R1 on each shift. However, the ADL had been left blank and no services were documented on the following dates: - April 4, 2024 on the, "7a-7p," shift; - April 5, 2024 on the, "7a-7p," shift; - April 6, 2024 on the, "7a-7p," shift; - April 12, 2024 on the, "7a-7p," shift; - April 13, 2024 on the, "7a-7p," shift; and - April 17, 2024 on the, "7a-7p," shift. 3. A review of R2's medical record revealed a service plan, dated January 5, 2024, for personal care services. The service plan included a list of services which would be provided to R2 each day. 4. A review of R2's medical record revealed a document titled, "Caregiver ADL Checklist," (ADL) dated April 2024, which documented the services provided to R2 on each shift. However, the ADL had been left blank and no services were documented on the following dates: - April 4, 2024 on the, "7a-7p," shift; - April 5, 2024 on the, "7a-7p," shift; - April 6, 2024 on the, "7a-7p," shift; - April 10, 2024 on the, "7a-7p," shift; - April 12, 2024 on the, "7a-7p," shift; - April 13, 2024 on the, "7a-7p," shift; and - April 17, 2024 on the, "7a-7p," shift. 5. In an interview, E1 acknowledged the services provided to each resident had not been documented in the provided records.

Based on documentation review, observation, and interview, the manager failed to ensure, for means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, the means of exiting controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. A documentation review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed a sliding glass door in the living room. The door did not control egress and was not equipped with a door alarm to alert employees of the egress of a resident from the facility. 3. During an environmental tour of the facility, the Compliance Officer observed an exit door at the end of a hallway between resident bedrooms. The door had a door alarm, however, the door alarm was found to be turned off at the time of the inspection. 4. In an interview, E1 acknowledged there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort which did not control or alert employees of the egress of the resident.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0F or below. Findings include: 1. During a facility tour, the Compliance Officer observed a pantry located adjacent to the kitchen. On the shelves in the pantry, the Compliance Officer observed two open containers of grape jelly, 2 open containers of frosting, and one open container of chocolate syrup. All five containers had labels indicating the food required refrigeration after opening. 2. In an interview, E1 acknowledged potentially hazardous foods requiring refrigeration were not maintained at 41\'b0F or below.