Villas at Green Valley, Villa B.

“Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or documentation from a medical practitioner which stated weighing the resident was contraindicated. The deficient practice posed a risk as the facility would not be aware if there was a significant change in R1's weight. Findings include: 1. A review of R1's medical record revealed a service plans dated August 6, 2024, which indicated R1 was receiving directed care services. The service plan did not include documentation of R1's weight. 2. Further review of R1's medical record revealed documentation from a medical practitioner which stated weighing R1 was contraindicated was unavailable for review. 3. In an interview, E1 reported R1's service plan was the most recent service plan available. E1 acknowledged R1's service plan did not contain the residents' weight, and R1's medical record did not contain documentation from a medical practitioner indicating weighing R1 was contraindicated.”