The Villas at Wilmot, Villa F

Based on record review and interview, the assisted living home failed to maintain a copy of the document provided to the emergency responder and documentation of the actions required by subsection B of this section. Findings include: 1. A review of R2's medical record revealed the facility had contacted emergency responders on R2's behalf on August 31, 2025. 2. During the on-site inspection, the Compliance Officer requested to review a copy of the documentation provided to the emergency responder, however, this documentation was not available for review. 3. In an interview, E1 reported the caregiver had not made a copy of the document given to the emergency responder. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the governing authority failed to ensure that a potential employee was not on the adult protective services registry pursuant to section 46-459 for one of two employee records reviewed. Findings include: 1 . A review of E2's personnel record revealed documentation of a search of the Adult Protective Services (APS) registry was not available for review. 2 . A search of the APS website was conducted by the Compliance Officer and revealed no record with APS. 3 . In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver accurately documented the services provided in a resident's medical record, for two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a current service plan for directed care services, which detailed the services R1 required, including assistance with showering, skin care, dressing, grooming, oral care, and toileting. 2. A review of R1's medical record revealed a document titled, "Caregiver ADL checklist," (ADL) dated August 10 through August 16, 2025. The ADL documented the services provided to R1 on each shift. However, the ADL indicated R1 was independent of bathing, skin care, oral care, dressing, and toileting. 3. A review of R2''s medical record revealed a current service plan for directed care services, which detailed the services R2 required, including assistance with showering, skin care, dressing, grooming, oral care, and toileting. 4. A review of R2's medical record revealed an incident report dated August 31, 2025 at 6:28 AM. The incident report indicated R2 was sent to the hospital due to a seizure. 5. A review of R2's medical record revealed a hospital discharge dated August 31, 2025 at 1:40 PM. 6. In an interview, E1 reported R2 was back at the facility around 2 PM on August 31, 2025. 7. A review of R2's ADL for August 2025 revealed on August 31, 2025, R2 had not received any services on the 7 AM to 7 PM shift or the 7 PM to 7 AM shift ending on September 1, 2025. Both shifts had been marked, "Hospital" indicating R2 was not present at the facility for the full 24 hour period. However, this contradicted the incident report and hospital discharge, which indicated R2 was out of the facility for approximately eight hours of the day shift and was not at the hospital at all on the overnight shift. 8. In an interview, E1 reported services were provided to each resident according to their service plans and the ADL documentation was not accurate. 9. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for two of two sampled residents. Findings include: 1. A review of R1's and R2's medical records revealed current service plans including medication administration. 2. A review of R1's and R2's medical records revealed signed medication orders for both residents. 3. A review of R1's and R2's medical records revealed electronic Medication Administration Records (eMARs) dated September 2025. The eMARs documented the medication administered to each resident on each day. However, for both R1 and R2, all 8 PM medications required to be administered on September 1, 2025, had not been documented to have been administered or to have had an exception preventing administration. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed a garbage can in bedroom #1 contained garbage. However, the garbage can did not have a lid. 2. During an environmental tour of the facility, the Compliance Officer observed the garbage cans in both shared resident bathrooms contained garbage. However, both garbage cans did not have lids. 3. During an environmental tour of the facility, the Compliance Officer observed a garbage can in bedroom #10 contained garbage. However, the garbage can was not lined with plastic bags. 4. In an interview, E1 acknowledged the manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags. Technical assistance for this rule was provided during the previous on-site compliance inspection conducted on November 8, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure an individual who administered an opioid in treating a patient documented in the patient's medical record an identification of the patient's need for the opioid before the opioid was administered and the effect of the opioid administered, for one of one residents sampled who were administered an opioid. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Opioid Prescribing, Ordering, Administration, Monitoring And Surveillance Quality Management Emergency Rule Effective 7/28/2017", which stated, "Before administering an opioid...the Certified Caregiver...will be responsible for....documenting on the respective Opioid Log Form for the following...The pain evaluation score assessed at time just prior to the initial dose of opioid medication...the pain evaluation score re-assessed two hours after the initial dose of opioid medication...The outcome of the opioid give as a result of the respective pain scale evaluation including, 1. Whether or not the resident has improved, 2. The pain is unchanged, 3. The pain has worsened, and/or, 4. The resident has had an adverse reaction or negative outcome to the opioid medication." 2. A review of R2's medical record revealed a service plan, dated October 4, 2023, for personal care services including medication administration. 3. A review of R2's medical record revealed a signed list of medication orders dated January 5, 2023. The list included orders for the following opioids: - "Buprenorphine HCI (Belbuca) 600 MCG, place 1 film via buccal BID"; and - "Hydromorphone HCI 2 MG Oral Tablet Give 1 tag PO QID." 4. A review of R2's medical record revealed a Medication Administration Record (MAR) dated October 2023. The MAR indicated the following: - For "Belbuca 600 MCG Film," the MAR indicated R2 had been administered this Opioid twice daily as ordered. However, the MAR did not include documentation of the identification of R2's need for the opioid and did not include documentation of the monitoring of R2 for the effect of the opioid; and - For "Hydromorphone 2 MG tablet," the MAR indicated R2 had been administered this Opioid four times daily as ordered and included documentation of the identification of R2's need for the opioid. However, the MAR did not include documentation of the monitoring of R2 for the effect of the opioid. 5. In an interview, E1 acknowledged the caregiver administering opioids to R2 had not documented the identification of the resident's need for the opioids or the effect of the opioids in the manner prescribed by the facility's policies and procedures.