Villas at Green Valley, Villa I

Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a service plan dated August 1, 2025, which indicated R1 received a variety of assisted living services, including medication administration. 2. A review of R1’s medical record contained a medication order dated October 4, 2025, for the following medication to be administered as indicated: Morphine Sulfate 100mg/5ml-0.25ml (5mg) by mouth every 4 hours for pain and/or shortness of breath A review of R1’s medical record contained a medication order dated October 9, 2025, for the following medication to be administered as indicated: Lorazepam 2mg 1ml, give 0.25 ml (0.5mg) by mouth every four hours for anxiety 3. Further review of R1’s medical record revealed a Medication Administration Record (MAR) which included sections for documenting the administration of Morphine Sulfate and Lorazepam; however, the documentation revealed Morphine Sulfate and Lorazepam were not administered on the following days and times: -October 10, 2025 at 12:00 a.m. and 4:00 a.m. 4. In an interview, the findings were reviewed with E1. E1 advised E2 was new to the facility and was not aware of R1’s medication change. E1 stated E2 did not administer the medication as ordered and an investigation was conducted.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical record for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated June 2, 2023, for directed care services, and indicated R1 would be provided the following services: "Showering: Complete Assist, 2x per week;" and "Dressing: Complete Assist, Daily." 2. A review of R1's medical record revealed a document titled "Caregiver ADL Checklist," for the month of July 2023, to document services provided and activities of daily living, during each of three shifts, 1, 2 and 3. The tracking sheet stated at the top, in red letters, "Each shift must initial completion of each ADL task." At the bottom of the tracking sheet, in red lettering, was a legend with codes used in the document, to include "Initials = Assistance Provided." Also at the bottom was a section for caregivers to write their name and enter their initials for documentation purposes. The tracking sheet contained sections for documenting various services to include, "Bathing," and "Dressing" which were documented as noted below on the shifts and dates indicated: Bathing: "N" or "NA" for Shift 1, 2 and 3 on July 2, 3, 6-31, 2023 "Y" for Shift 1 and 2 on July 3, 2023; and "Y" for Shift 2 on June 5, 2023 Dressing: "Y" or initials for each shift on July 1-7, 9-13 and 16-22, 2023; "Y" or initials for Shift 1 and 2 and "NA" for shift 3 on July 8, 14, 15, 30 and 31, 2023; and "Y" for Shift 1 and 2, and no documentation for Shift 3 on July 23-26, 2023. 3. A review of R2's medical record revealed a service plan dated May 19, 2023, for directed care services, and indicated R2 would be provided the following services: "Showering: Monitor, 2x per week." 4. A review of R2's medical record revealed a document titled "Caregiver ADL Checklist," for the month of July 2023, to document services provided and activities of daily living, during each of three shifts, 1, 2 and 3. The tracking sheet stated at the top, in red letters, "Each shift must initial completion of each ADL task." At the bottom of the tracking sheet, in red lettering, was a legend with codes used in the document, to include "Initials = Assistance Provided." Also at the bottom was a section for caregivers to write their name and enter their initials for documentation purposes. The tracking sheet contained sections for documenting various services to include, "Bathing,"which was documented as noted below on the shifts and dates indicated: Bathing: "I" for Shift 1 and 3, and "NA" for Shift 2 on July 1, 2023; "I" for all shifts on July 2-5, 7 and 9-12, 2023; "I" for Shift 1 and 2, and "NA" for Shift 3 on July 6 and 8, 2023; "I" for all shifts on July 9-12, 2023; "I" for Shift 1 and 3, and no documentation for Shift 2 on July 13, 2023; no documentation for Shift 1 and 2, on July 14 and 15, 2023; "N" for Shift 1 and 2, and "I" for Shif

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination influenza (flu) and pneumonia were offered every 12 months, for one of two residents sampled. Findings include: 1. A review of R2's (admitted August 2021) medical record revealed documentation of notification the flu vaccine. However, evidence of documentation of the availability of the pneumonia vaccine was offered or received was unavailable for review. 3. In an interview E1 acknowledged R2's medical record did not contain evidence of documentation of the availability of the pneumonia vaccine being offered.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, separate from medications and inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed no fewer than three ambulatory residents in the common area near the kitchen of the residence. Two caregivers, E2 and E3, were on duty and were observed to leave the kitchen area and go into the back of the residence for several minutes, leaving the kitchen unattended. The Compliance Officer also observed a cabinet under the kitchen sink which was equipped with magnetic locks to secure the doors, however the locks were not engaged. The Compliance Officer was able to open the cabinet with little effort and observed a one gallon bottle of Clorox bleach, an open canister of Comet scouring powder, a bottle of Windex, a can of Old English furniture polish, and a clear, plastic spray bottle with no label containing a clear, brown liquid. 2. In an interview, E2 acknowledged the magnetic locks had not been engaged. E2 advised the unlabeled plastic spray bottled contained apple cider vinegar. E2 obtained the magnetic key, closed the cabinet doors and engage the magnetic locks. 3. In an interview E1 acknowledged the poisonous and toxic materials were not kept in a locked area, inaccessible to residents.