Villa Serene Assisted Living II.

“Based on interview and documentation review, the manager failed to ensure a medical record contained the requirements in R9-10.811.C.1-24, for one of three residents sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. In an interview, E1 reported R3 was a resident of the facility in 2024. However, E1 was unable to provide R3's admission or discharge dates. 2. An "Onsite Compliance Inspection Document Request" was completed at 10:00AM on April 16, 2026 requesting R1's, R2's, and R3's medical records. However, R3's medical record was not provided for review. 3. In an interview, E1 reported R3's medical record was in storage and was not available.  4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager retained a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, without meeting the requirements in R9-814(B)(2), for one of two residents sampled who received directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R1's updated service plan dated January 10, 2025, revealed R1 received directed care services. 3. A review of R1's medical record contained a document titled "Initial Physician Recommendation Form," dated July 30, 2024. This document stated R1 was confined to a bed or chair (bedbound). Based on this date, further documentation was required. 4.In an interview, E1 acknowledged that R1's medical record did not include the required determination per R9-10-814(B)(2), updated at least once every six months.”

“Based on record review and interview, the manager failed to ensure medications were administered to a resident in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a health and safety risk to residents if the facility did not administer medications in compliance with a medication order and a resident did not receive medication as ordered.   Findings include: 1. A review of R1's medical record revealed a medication order dated February 28, 2025. The order stated, "Stopped [sic] Tamsulosin 0.4mg capsule: Take 1 capsule by mouth once a day." 2. A review of R1's medical record revealed a Medication Administration Record (MAR) for March 2025. The MAR reported Tamsulosin 0.4mg was administered from March 1, 2025, to March 6, 2025, inclusively. 3. The Compliance Officers observed a medication organizer and a bottle of Tamsulosin medication. The medication organizer contained the Tamsulosin pills for the remaining days of the week. 4. In an interview, E1 reported that many of R1's medications were stopped. E1 acknowledged R1 was not administered medication in compliance with the medication orders located in R1's medical record.”