Villas at Green Valley, Villa D

Based on record review and interview, the manager failed to ensure a service plan included the care instructions for one of two residents receiving services from a hospice service agency. The deficient practice posed a health risk to the resident if the caregiver did not know the hospice instructions. Findings include: 1. Review of R1's medical record revealed R1 was receiving home health services from Santa Rita Home Health. 2. Review of R1's medical record revealed documentation titled, "Skilled Nursing Visit," dated April 22, 2024, which detailed an encounter between R1 and a nurse representative from Santa Rita Home Health. The document included a section titled, "Goal Progress Summary For This Visit," which indicated "SN to instruct the patient and caregiver on proper foley care. Result: Verbalized Understanding. Performed On: Patient, Caregiver." The document also included a "Comments:" section which outlined in detail "Foley Catheter Drainage Bag Care," to include "1. Drain the Bag," and instructions on proper personal hygiene as well as cleaning of the device and associated tubing. 3. Review of R1's service plan dated February 29, 2024, revealed a section titled, "Adaptive Devices/Prosthetics," which indicated R1 had a catheter and required "Complete Assist." Further, the service plan contained a section titled, "Home Health Agency," which identified Santa Rita, however the section contained no documentation of the care instructions for R1's foley catheter. 4. Further review of R1's medical record revealed a document titled, "Change in Resident Condition," which indicated R1 "was complaining of pain in [genitalia]." The document reflected a representative from Santa Rita Home Health would not be able to respond until the following day, and R1 was sent to the emergency department. 5. During an interview, E1 acknowledged R1's service plan did not include the care instructions for R1's catheter.