Villas at Green Valley, Villa E

Based on document review, record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for one of two residents sampled. Findings include: 1. During a tour of the facility the Compliance Officer observed R1 sitting in their recliner chair. A pad attached to an electrical cord was laying on the floor, several feet away from the chair. The Compliance Officer also observed an electrical cord coming from under R1's bedding. 2. In an interview E1 advised that the pad on the floor was a "chair alarm." E1 indicated the chair alarm was not placed under the seat cushion of the chair as it should have been. E1 reported the electrical cord coming from under R1's bed was part of a similar bed alarm. 3. A review of R1's medical record revealed a current service plan indicating R1 received directed care services. R1's service plan indicated R1 was a "Fall Risk," and included the service "Bed Alarm," and "Chair Alarm." 4. In an interview, E1 agreed R1 was not provided the service chair alarm as described in R1's service plan.

Based on record review and interview, the manager failed to ensure a therapeutic diet was provided to a resident according to a written order from the resident's primary care provider or another medical practitioner, for one of two residents with orders for a therapeutic diet, which posed a health and safety risk. Findings include: 1. A review of R1's medical record revealed a service plan dated November 17, 2023 for directed care services. The service plan stated R1 would receive: "Regular diet, thin liquids." 2. A review of R1's medical record revealed a form titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," signed by a medical practitioner and dated September 17, 2023, which stated, "Mechanical Soft Diet." 3. In an interview, E1 agreed R1 had not been provided with a therapeutic diet as ordered.