Villa Jean I LLC

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. While on-site for the compliance inspection, the Compliance Officer observed E3, E4, and E5 working at the facility independently at 12:00 PM. 2. A review of the facility's employee work schedule revealed a schedule for January 2026. The schedule indicated E3 was scheduled to work independently from 7:00 AM - 7:00 PM. No further documentation of the caregivers scheduled to work and hours worked by each was available for review. 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 that a resident had a service plan that was established, documented, and implemented, which included a description of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of two residents sampled. Findings include: 1. A review of R4’s medical record revealed a service plan, dated October 21, 2025. However, the service plan did not include a description of the resident's medical or health problems. 2. 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 medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During an environmental tour, the Compliance Officers observed 4 bottles of eye drops in an unsecured kitchen drawer. 2. In an interview, E3 reported E3 had placed the eye drops in the drawer because E3 was going to administer them. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documention review, and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a risk to the health and safety of the residents. Findings include: 1. During an environmental tour, the Compliance Officers observed one small oxygen cylinder on the garage floor. The cylinder was lying horizontally among other oxygen cylinders and unsecured. 2. A review of the facility’s policies and procedures revealed a policy titled”Environmental Safety,” which stated, ”Oxygen containers are secured in an upright position.” 3. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documention review, and interview, the manager failed to ensure that toxic materials stored by the facility were stored in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of the resident. Findings include: 1. During an environmental tour, the Compliance Officers observed one large bottle of dish soap and one large bottle of dishwasher gel in an unlocked cabinet under the kitchen sink. There was also a small unlabeled bottle containing dish soap placed on the sink. 2. A review of the facility’s policies and procedures revealed a policy titled “Environmental Safety,” which stated, “Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation.” 3. In an interview, E1 reported E1 was unaware that the bottles needed to be locked up. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided