Venezia Place, LLC

Based on documentation review and interview, the assisted living home failed to maintain a copy of the document provided to an emergency responder and documentation of the actions required by subsection B of this section for a period of two years after the date of an emergency. Findings include: A review of facility incident reports revealed an incident report for R2, dated January 24, 2026 at 11 AM. The incident report stated, "Caregiver [E1] given another resident a shower. When done, came to the living room, saw a big pool of water (it was urine). [R2] is the only one that pee everywhere. [R2] was walking around. Check on [R2's] pants to change [R2] and [R2] had blood on [R2's] head, figured out [R2] fell backward on the pool of pee. Actions Taken: 911 Called: Yes, Time they arrived 11:10 AM...." During the on-site inspection, the Compliance Officer requested to review the facility's copy of the information given to the emergency responder for R2 on January 24, 2026. In an interview, E1 reported the paramedics were provided with the emergency responder information for R2, however, E1 reported a copy of that information was not available for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure, for one of two sampled residents, a service plan was established and documented which included the amount, type, and frequency of assisted living services being provided to the resident. Findings include: 1. In an interview with R2, the Compliance Officers observed R2's right foot was wrapped in gauze. Additionally, the Compliance Officers observed a catheter hanging on the side of R2's bed. 2. A review of R2's medical record revealed a document titled, "Initial Medication/Treatment Plan of Care," which was signed and dated by a nurse practitioner on February 17, 2025. This document stated, " Catheter flushes - to be performed by hospice. Clean wound to right toe with wound cleanser, pat dry, cover with foam and secure with tape two times weekly or PRN if not by hospice." 3. A review of R2's medical record revealed a hospice order, dated February 24, 2025, which stated, "New wound care orders: To wound to right third toe, cleanse with wound cleaner, apply medihoney, cover with gauze, warp with kurlex and secure with tape 2x/week. Treatment to be done by [hospice] nurse." 4. A review of R2's medical record revealed a hospice plan of care update, dated March 10, 2025, which stated, "Foley catheter will remain patent; caregivers will understand care and irrigation of foley catheter." 5. A review of R2's medical record revealed a service plan, updated June 7, 2025, for directed care services. However, the service plan did not include a description of the wound care or foley care services required by R2. 6. In an interview, E1 acknowledged the service plan for R2 did not include the amount, type, and frequency of assisted living services being provided to R2, to include wound care and foley care.

Based on observation and interview, the manager failed to ensure cooling systems maintained the assisted living facility at a temperature between 70° Fahrenheit (F) and 84° F at all times. Findings include: 1. Upon entering the facility at approximately 8:55 AM, the Compliance Officers observed a thermostat in the hallway near the entrance door read 85° F. The thermostat was set to 77° F and the thermostat indicated the system was on. 2. The Compliance Officers observed the bedrooms on the west side of the facility, the kitchen, dining room, and main living room were all 85° F. The Compliance Officers observed the bedrooms on the east side of the facility had window A/C units, and a second living room at the east end of the building had a separate A/C system. The east side of the facility measured at 75° F on the Compliance Officers infrared meter. 2. The Compliance Officers observed air was blowing from the air conditioning (A/C) vents, however, the air temperature measured at 86° F on the Compliance Officer's infrared meter. 3. The Compliance Officers observed an A/C compressor outside on the west side of the facility. However, the compressor was not running despite the system being on. 4. E1 and E2 attempted to reset the A/C system, however, they were unsuccessful and stated they were contacting a repair service. 5. The Compliance Officers observed the facility staff immediately moving all residents to the east side living room and bedrooms. 6. The Compliance Officers observed an A/C repair service arrived at approximately 11:40 AM and the A/C system began functioning at 12:00 PM. 7. In an interview, E1 reported the A/C had been working the previous day and they were unaware it had stopped working the morning of the inspection. E1 acknowledged the facility had not been maintained between 70° F and 84° F at all times.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R2's medical record revealed documentation of R2's freedom from infectious TB was not available for review. R2's medical record included two chest X-rays and a baseline screening questionnaire, however, R2's medical record did not include a skin or blood test for Tuberculosis. 3. In an interview, E1 acknowledged documentation of R2's freedom from infectious TB had not been provided for review

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 were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed an unlocked closet in a hallway which contained incontinence supplies and personal protective equipment. Also in the closet, the Compliance Officer observed a container of, "XP200 Blonding lightener," which included a hazard warning label. 2. In an interview, E1 acknowledged poisonous or toxic materials stored by the facility were not stored in a locked area inaccessible to residents. This is a repeat deficiency from the onsite compliance inspection conducted on June 28, 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 an environmental inspection of the facility, the Compliance Officer observed a sliding glass door in the dining room had a door alarm, however, the alarm was missing the magnet and did not alarm when the door was opened. The Compliance Officer observed a stick had been placed in the track of the door to prevent the door from opening, however, the stick did not require a key, code, or special knowledge to remove. The sliding glass door opened to the back yard of the facility, which was secured with a fence and locked gates. 3. In an interview, E1 acknowledged there were means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility which did not control or alert employees of the egress of a resident from the facility.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, updated March 21, 2023, for personal care services including medication administration. 2. A review of R1's medical record revealed a verbal order, signed by two registered nurses, dated January 23, 2023. This verbal order included, "Add Seroquel 25 MG tablet, PO one tab daily in the AM. D/C Seroquel 25 MG tablet: PO One tab at Noon." 3. A review of R1's medical record revealed a medication order, signed by a medical practitioner dated June 22, 2023. This medication order included: - "Seroquel 25 mg tablet, 1 tablet, take one 25 mg tab of Seroquel by mouth at noon, Start Date 11/22/2022." 4. A review of R1's medical record revealed a medication order, signed by a medical practitioner dated June 22, 2023. This medication order included: - "Seroquel 25 mg tablet, 1 tablet, take one 25 mg tab of Seroquel by mouth at noon, Start Date 11/22/2022." 5. A review of R1's medical record revealed a Medication Administration Record (MAR) dated May 2023. The MAR included the following medication, "Quetiapine 24 mg PO one tab QD 7a," and indicated R1 had been provided Quetiapine on each day in May 2023 at 7 am. 6. In an interview, E2 reported R1's hospice provider verbally ordered the morning dose of Quetiapine in January 2023, and the subsequent orders to provide the 25 milligram dose at noon were incorrect and would be clarified with the provider. 7. A review of R2's medical record revealed a service plan, updated April 20, 2023, for personal care including medication administration. 8. A review of R2's medical record revealed a list of medication orders dated March 22, 2022, which included, "Haloperidol 10 MG Tab(s), Oral, 1 tab, daily." 9. A review of R2's medical record revealed a list of medication orders dated June 2, 2023, which included, "Haloperidol Tab, Take 15 MG by Mouth Every day." 10. A review of R2's medical record revealed a MAR dated June 2023. The MAR included the following medication, "Haloperidol 10 mg PO one tab QD," and indicated R2 had been provided 10 milligrams of Haloperidol on each day in June 2023 at 7 am. 11. The Compliance Officer observed a box containing R2's medications included a bottle of 10 milligram Haloperidol tablets. 12. The Compliance Officer observed a medication organizer containing R2's medications. The Compliance Officer observed the medication organizer did not include a half tablet of 10 milligram Haloperidol tablets. 13. In an interview, E1 acknowledged R2's Haloperidol dosage had not been increased as ordered. E1 acknowledged R1's and R2's medication had not been administered as ordered. This is a repeat deficiency from the on-site complaint inspection conducted on June 12, 2023.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet located in a hallway between the laundry room and a shared bathroom had a lock, however, the cabinet had been left unlocked. Inside the cabinet, the Compliance Officer observed a bottle of "Fabuloso Multi-Use Cleaner." 2. In an interview, E1 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative when initially developed and when updated, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated January 28, 2023, for personal care services. However, the service plan was not signed and dated by R1 or R1's representative. 2. In an interview, E1 acknowledged the service plan provided for R1 had not been signed and dated by R1 or their representative when the plan was developed or updated.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, updated May 8, 2023, for personal care services including medication administration. 2. A review of R2's medical record revealed an unsigned medication order dated April 14, 2023. This medication order included: - "Hydralazine HCI Oral Tablet 25 MG, Give 1 tablet by mouth every 8 hours for HTN, Hold for SBP less than 110." 3. A review of R2's medical record revealed a blood pressure log. R2's blood pressure had been documented only two times per day. R2's blood pressure was less than 110 on the following days and times: - May 10, 2023, AM, 106/68; - May 11, 2023, AM 108/74; - May 15, 2023, AM 105/65; - May 16, 2023, AM 109/68; - May 17, 2023, AM 109/64; - May 18, 2023, AM 93/56; and - May 22, 2023, AM 99/64. 4. A review of R2's medical record revealed a Medication Administration Record (MAR) dated May 2023. The MAR included the following medication, "Hydralazine HCI/ 25 MG PO Q8, hold if sbp less than 100." However, the MAR indicated the medication was administered at 7 AM and at 7 PM on each day in May 2023 and had not been administered every 8 hours as ordered. Additionally, the MAR did not indicated R2's Hydralazine had been held at any time in May 2023. 5. In an interview, E1 reported R2's Hydralazine had been held but had not been documented to have been held. E1 acknowledged the MAR provided for R2 indicated medication had not been administered to R2 as ordered.