The Villas at Wilmot, Villa G.

“Based on record review and interview, the manager failed to ensure a service plan was documented for a resident who required behavioral care to accurately include the psychosocial interactions or behaviors for which the resident requires assistance, psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors, for one of one sampled residents who required behavioral care. Findings include: A review of R2's medical record revealed a behavioral health provider progress note, dated January 20, 2026. The note stated, "Formulation: [R2].. Hx of Unspecified Somatic Symptom and related disorder, unspecified personality disorder, hypothyroidism, HLD, paroxysmal a-fib, depression, who presented to the ED after calling [A behavioral health crisis provider] for mental health decline w/o SI. Initially going to [A behavioral health crisis center] but taken to [A hospital] for med clearance. Once medically clear, then began to endorse SI w/plan to hang [R2] after being told [R2] would have to return to [The behavioral health crisis center], for which psychiatry was consulted. Patient continues to endorse insomnia despite sleeping 8 hours per nursing report. [R2] reports significant depression and anxiety in the setting of insomnia for the last several weeks." A review of R2's medical record revealed a Behavioral Care Service Plan, dated January 22, 2026. The service plan included the following information: In the section "Psychosocial Interactions / Behaviors Requiring Assistance," the service plan stated, "None." However, two days prior, R2 was hospitalized due to suicidal ideation, depression, and anxiety related to insomnia; In the section "Interaction/Behavior: Planned Strategies/Actions," the service plan stated, "None"; and In the section "Goals for Changes in Psychosocial Interactions / Behaviors and Frequency," the service plan stated, "None." A review of R2's medical record revealed a Behavioral Care Service Plan, dated February 2, 2026. The service plan included the following information: In the section "Psychosocial Interactions / Behaviors Requiring Assistance," the service plan stated, "major depressive disorder, insomnia (attention seeking, depression, isolation)." However, it listed both diagnoses and behaviors, and did not include suicidal ideation; and In the section "Goals for Changes in Psychosocial Interactions / Behaviors and Frequency," the service plan stated, "encourage to do as much on [R2's] own to minimize behaviors." In an exit interview with E1, the findings were reviewed and no additional information was provided”

“Based on documentation review, record review and interview, the manager failed to ensure a caregiver documented the services provided in a resident's service plan, for eight of nine residents sampled.   Findings include:   1. A review of facility staff schedules revealed the facility operated two shifts per day, 7 a.m. to 7 p.m., and 7 p.m. to 7 a.m.   2. A review of R1’s medical record revealed a service plan, dated February 13, 2025, for directed care services. The service plan included the provision of showering twice per week to include, "Set-up," and "Standby," and stated, "See shower schedule for current days. Document when showers are given."   3. A review of R1’s medical record revealed a document, titled, "Caregiver ADL Checklist" used for tracking activities of daily living (ADLs), Dated March, 2025. The document included sections for documenting the service “Bathing” The ADL documented the following showering services were provided during March, 2025: On March 4, 2025, on the "7a-7p" shift, "Bathing" was marked with an "R" to indicated R1 refused the shower; On March 10, 2025 on the "7a-7p" shift, "Bathing" was initialed to indicate the showering service was provided; On March 17, 2025 on the "7a-7p" shift, "Bathing" was initialed to indicate the showering service was provided; and On March 19, 2025, on the "7a-7p" shift, "Bathing" was marked, "Y." 4. A review of R2’s medical record revealed a service plan, dated January 13, 2025, for directed care services. The service plan included the provision of showering twice per week to include, "Complete," and stated, "See shower schedule for current days. Document when showers are given."   5. A review of R2’s medical record revealed a document, titled, "Caregiver ADL Checklist" used for tracking activities of daily living (ADLs), Dated March, 2025. The document included sections for documenting the service “Bathing” The ADL documented the following showering services were provided during March, 2025: On March 2, 2025 on the "7a-7p" shift, "Bathing" was initialed to indicate the showering service was provided; On March 9, 2025 on the "7a-7p" shift, "Bathing" was initialed to indicate the showering service was provided; On March 16, 2025 on the "7a-7p" shift, "Bathing" was initialed to indicate the showering service was provided; On March 21, 2025, on the "7a-7p" shift, "Bathing" was marked, "S"; On March 23, 2025 on the "7a-7p" shift, "Bathing" was initialed to indicate the showering service was provided; and, On March 19, 2025, on the "7a-7p" shift, "Bathing" was marked, "Y." 6. A review of R4's, R5's, R6's, R7's, R8's, and R9's ADLs for March 2025 revealed, on March 26, 2025, on both shifts, the ADL was entirely blank and the services provided to each resident had not been documented for the 24 hour period.  7. In an interview, E1 acknowledged the ADL documentation provided for each resident did not accurately document the services provided to each resident.”

“Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41°F or below. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed a refrigerator in the kitchen. The refrigerator contained foods requiring refrigeration, such as butter, mayonnaise, and other perishable foods. However, a thermometer in the refrigerator read 52°F.   2 . During the on-site inspection, E1 had a second thermometer placed in the refrigerator. Prior to the exit interview, the Compliance Officer re-checked the refrigerator. At this time, the second thermometer read 45°F.  3 . The Compliance Officer observed the refrigerator was set to 33°F.  4. In an interview, E1 acknowledged foods requiring refrigeration had not been maintained at 41°F or below. E1 reported it was possible both thermometers were defective, but if additional thermometers also agreed, the refrigerator would be serviced.”

“Based on documentation review, record review, and interview, the manager failed to ensure a resident's written service plan included the psychosocial interactions or behaviors for which the resident required assistance; the psychotropic medications ordered for the resident; the planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and the goals for changes in the resident's psychosocial interactions or behaviors, for one of one resident reviewed who required behavioral care. Findings include: 1. R9-10-101(29) defines "Behavioral care" a. means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services. 2. A review of R1's medical record revealed a document signed by a medical practitioner, titled, "Behavioral Health Care Authorization," dated October 18, 2023, which stated, "...We provide behavioral care and our staff is able to assist with your patient's psychosocial interactions and medications to manage behavior under the direction of a behavioral health professional and/or a medical practitioner. We do not provide continuous behavioral health services. Attached is a copy of our facility's scope for your review... Your authorization is required at the date of acceptance into our facility, and at least once every six months throughout the duration of your patient's need for behavioral care...Please sign and date, and return this form to use as soon as possible. We are unable to admit or retain your patient until we are in receipt of this form..." 3. A review of R1's medical record revealed a document signed by a medical practitioner, titled, "Provider Approval for Admission into the Villas," dated October 18, 2023. The form stated, "Does this person require behavior care which can be provided by Certified Caregivers?," and had been marked, "Yes." 4. A review of R1's medical record revealed a progress note from a skilled nursing facility dated October 12, 2023. The note stated, "Patient has a past medical history of anemia, HTN, hearing loss, hypothyroidism, OA, colon cancer stage 1, constipation, SI, dementia, and MDD. Medical records note that the patient was brought into [A hospital] [in October] by [their representative] for concerns for suicidal ideation. [R1] had a full work up including labs and psychiatry evaluation. Labs were unremarkable. [R1] was admitted [in October] for observation....Assessment/Plan:....F32, MDD Monitor behaviors, Continue Citalopram/Amitriptyline as directed. New order for in house BH Provider for evaluation and treatment." 5. A review of R1's medical record revealed an order summary from a skilled nursing facility dated October 11, 2023. The order summary included: - "Monitor behavior every shift for depression episodes AEB Target Behavior: Self Isolation, every shift"; - "Monitor side effects every shift of anti-depressant medication: (Sedation, Drowsiness, Headache, Decreased appetite, Less common S/e: Dry mouth, blurred vision, urinary retention, rare S/E: Extra pyramidal) every shift **Notify provider if present.**; - "May place in secure unit if needed"; - "Please place referral for in house psychiatry provider Dx Dementia/MDD/SI"; - "Amitriptyline HCI Oral Tablet 10 MG, Give 1 tablet by mouth at bedtime for Depression aeb self isolation"; - "Citalopram Hydrobromide 20 MG, Give 1 tablet by mouth one time a day for Depression aeb self isolation." 6. A review of R1's medical record revealed a service plan, dated November 20, 2023, for directed care services. The service plan stated R1's diagnoses included, "...depression, vascular dementia, hx of suicide ideations.." However, the service plan did not include the psychosocial interactions or behaviors for which the resident required assistance; the psychotropic medications ordered for the resident; the planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and the goals for changes in the resident's psychosocial interactions or behaviors. 7. In an interview, E1 acknowledged R1's doctor had requested and authorized behavioral care services to be provided to R1, and R1's medical history documented behavioral care needs at R1's prior placement, however, R1's service plan did not detail the behavioral care which would be provided to R1.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated January 10, 2024, for directed care services. The service plan included a list of services which would be provided to R1 each day. 2. A review of R1's medical record revealed a document titled, "Caregiver ADL Checklist," (ADL) dated April 2024, which documented the services provided to R1 on each shift. However, the ADL had been left blank and no services were documented on the following dates: - April 1, 2024 on the, "7a-7p," shift; - April 10, 2024 on the, "7a-7p," shift; - April 14, 2024 on the, "7a-7p," shift; - April 15, 2024 on the, "7a-7p," shift; and - April 16, 2024 on the, "7a-7p," shift. 3. A review of R2's medical record revealed a service plan, dated March 2, 2024, for personal care services. The service plan included a list of services which would be provided to R1 each day. 4. A review of R2's medical record revealed a document titled, "Caregiver ADL Checklist," (ADL) dated April 2024, which documented the services provided to R2 on each shift. However, the ADL had been left blank and no services were documented on the following date: - April 11, 2024 on the, "7a-7p," shift. 5. In an interview, E1 acknowledged the services provided to each resident had not been documented in the provided records.”

“Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A documentation review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During a facility tour, the Compliance Officer observed the rear door of the facility had a door alarm. However, the door alarm did not sound an alert when the Compliance Officer opened the door. The rear door led to a fenced and secured outside area. 3. In an interview, E1 acknowledged a resident could egress through either the back door without alerting a caregiver to the egress of the resident.”

“Based on record review, interview, and record review, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication, and false or misleading information was provided to the department. Findings include: 1. A review of R1's medical record revealed a service plan, dated January 10, 2024, for directed care services. However, the service plan did not include whether R1 would receive assistance in the self administration of medication or medication administration as required. 2. In an interview, E2 reported a current service plan dated within three months of the inspection date was not available. E2 reported R1 receives medication administration for all medications. 3. A review of R1's medical record revealed an order, dated April 5, 2024 , for "Tramadol 50 MG tablet 1 tablets orally every 6 hours for severe pain, PRN severe pain." 4. A review of R1's medical record revealed a medication administration record (MAR) dated April 2024. The MAR indicated Tramadol had been administered on April 12, 2024 at 12:45 PM, and at 5:26 PM, a time difference of less than six hours between doses. 5. A review of R2's medical record revealed a service plan, dated March 2, 2024, for personal care services including medication administration. 6. A review of R2's medical record revealed an order, dated December 5, 2023, for "Levothyroxine 25 mcg, 1 tab daily 30 minutes before a meal." 7. A review of R2's medical record revealed an order to discontinue Levothyroxine had not been provided for review. 8. The Compliance Officer requested to observe R2's container of Levothyroxine, however, E1 reported this medication was not available. 9. A review of R2's medical record revealed a medication administration record (MAR) dated April 2024. The MAR indicated the following: - On April 1, 2024 and April 2, 2024, Levothyroxine had been administered as ordered; - On April 3, 2024, Levothyroxine was correctly marked unavailable; - On April 4, 2024, Levothyroxine was signed as administered, however, this was false and misleading as the medication was not available; - On April 5, 2024, Levothyroxine was correctly marked unavailable; - On April 6, 2024, Levothyroxine was signed as administered, however, this was false and misleading as the medication was not available; - On April 7, 2024, the MAR had been left blank; - On April 8, 2024, Levothyroxine was correctly marked unavailable; - On April 9, 2024, Levothyroxine was signed as administered, however, this was false and misleading as the medication was not available; - On April 10, 2024, and April 11, 2024, Levothyroxine was correctly marked unavailable; - On April 12, 2024, April 13, 2024, and April 14, 2024, Levothyroxine was signed as administered, however, this was false and misleading as the medication was not available; - On April 15, 2024, April 16, 2024, and April 17, 2024, Levothyroxine was correctly marked unavailable; and - On April 18, 2024, Levothyroxine was signed as administered, however, this was false and misleading as the medication was not available. 10. In an interview, E1 acknowledged medications had not been administered in compliance with a medication order, R2 had gone at least 15 days without an ordered medication or an order to discontinue an ordered medication, and medications marked as administered had not been provided as documented.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in labeled containers and stored in a locked area and inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed an unlocked cabinet in the kitchen containing bleach, furniture polish, floor cleaner, and unlabeled spray bottles of purple and yellow liquid. 2. In an interview, E1 acknowledged poisonous or toxic materials were not stored in a locked area and inaccessible to residents.”