Pleasant Lake Villa

Based on record review and staff interviews, the facility failed to ensure residents were evacuated during fire drills as required. This had the potential to affect all 15 residents residing at the facility. The facility census was 15.

Findings include:

Review of the monthly fire drill reports for the period of July 2025 to March 2026 revealed the facility conducted monthly fire drills on 07/31/25, 08/30/25, 09/22/25, 10/31/25, 11/28/25, 12/30/25, 01/27/26, 02/09/26, and 03/31/26. Each of the fire drill reports, except for the 09/22/25 report, indicated no residents were evacuated during the fire drills. Continued review revealed the fire drill report dated 09/22/25 had the section regarding resident evacuations blank and did not indicate whether residents were or were not evacuated during the drill.

Interview on 04/22/26 at 11:30 A.M. with Maintenance Director #3 confirmed the fire drill reports were missing information on evacuation of residents during the fire drills.

This violation is a recite to the annual survey completed 07/10/25.

Based on record review and staff interview, the facility failed to ensure written records of fire drills contained an evaluation of the facility fire drills. This had the potential to affect all 15 residents residing at the facility. The facility census was 15.

Findings include:

Review of the monthly fire drill reports for the period of July 2025 to March 2026 revealed the facility fire drills did not consistently include an evaluation of the fire drills. The fire drill reports dated 09/22/25, 10/31/25, 11/27/25, 12/30/25, 01/27/26, and 03/31/26 did not include if any problems or issues were encountered and if any corrective action was needed during the fire drills.

Interview on 04/22/26 at 11:30 A.M. with Maintenance Director #3 confirmed the fire drill reports were missing an evaluation of the fire drills on the above referenced dates.

Based on observation, record review and interview the facility failed to ensure medication was administered as required. This affected one resident(Resident #14) of two residents observed for medication administration. The total census was 15.

Findings include:

Observation of Licensed Practical Nurse (LPN) #201 on 07/10/25 at 8:43 A.M. revealed she left nine pills in a medication cup at the bedside of Resident #14 without observing him swallow the pills.

Record review of Resident #14 revealed he had a functional assessment dated 05/07/25 which said Resident #14 required staff to manage his medications. He had an active order dated 02/06/25 saying he was not allowed to self-administer medications.

Interview with LPN #201 on 07/10/25 at 9:30 A.M. confirmed the above findings.

Record review of the facility's medication administration policy dated 11/2021 revealed residents can only self administer when specifically authorized by the physician.

Based on record review and interview, the facility failed to ensure residents were evacuated during fire drills. This had the potential to affect all 15 residents in the facility.

Findings include:

Record review of monthly fire drills from July 2024 to June 2025 revealed no documentation of any resident evacuation from affected areas during the drills.

Interview with Maintenance Director #301 on 07/10/25 at 11:08 A.M. confirmed the above findings.

Based on record review and interview, the facility failed to educate residents on what to do in case of fire. This affected five of five (Resident #6, #8, #9, #10 and #14) residents reviewed for fire training. This had the potential to affect all residents. The census was 15.

Findings include:

Record review revealed Resident #6, #8, #9, #10 and #14 did not have fire safety training in their records.

Interview with Director of Nursing at 12:30 P.M. confirmed none of the residents in the facility had fire safety training.

Based on observation, staff interview, and policy review the facility failed to ensure medications were stored in a secure and sanitary manner. This affected all 14 residents residing in the facility at the time of the survey. This affected one of one medication carts used at the facility. The facility census was 14.

Findings include:

Observation of the medication cart on 04/24/23 between 11:59 A.M. and 12:12 P.M. with Licensed Practical Nurse (LPN) #548 revealed 51 unidentified loose pills at the bottom of multiple drawers throughout the medication cart. The medication cart was also littered with miscellaneous debris including but not limited to plastic from the medication punch cards, broken pill capsules, rubber bands, and residue from open or cracked pills.

LPN #548 verified the findings at the time of discovery.

Review of the facility policy titled Storage of Medications

Based on observation, record review, and staff interview the facility failed to ensure resident medical records (bathing records and skin checks) were kept private and secure and not accessible to others. This had the potential affect all residents residing in the facility. The facility census was 14.

Findings include:

Observation of the common area of the facility on 04/24/23 at 3:10 P.M. revealed a three-shelf bookshelf in the center of the unit. On the bottom shelf was a binder with title Woods (name for unit) Showers. The book contained shower records and skin checks for all residents residing on the unit for approximately the last thirty days.

Minimum Data Set (MDS) Nurse #636 verified the placement of the medical records in the common area during an interview on 04/24/23 at 3:20 P.M.