Villas at King Road, The, Villa B.

“Based on observation, document review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before providing physical health services or behavioral health services for two of two personnel members sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs.   Findings include:   During an onsite survey, the Compliance Officer observed E3 was the only caregiver working and providing physical health services. A review of facility staffing schedules revealed E4 worked February 10, 11, 12, 13, and 14, 2025. A review of E4's personnel record revealed E4 was hired on March 4, 2024, as an assistant caregiver. A review of E3's and E4's personnel records revealed a document titled "Employee Skills and Knowledge Record." The document contained a list of skills and knowledge to be verified and a column titled "Observed & Completed (mgr/designee Initial & date)," used for documenting verification of the corresponding skills and/or knowledge. While the document in E3's and E4's personnel record was signed by a manager's designee, the column titled "Observed and Completed," was blank. In an interview, E1 agreed the manager's designee did not complete the form properly, and the form did not contain evidence of documentation of verification of E3's and E4's skills and knowledge before providing physical health or behavioral health services.”

“Based on record review and interview, the manager failed to ensure a caregiver who was expected to have more than eight hours per week of direct interaction with residents provided evidence of freedom from infectious tuberculosis on or before the date the individual began providing services at the assisted living facility. The deficient practice posed a potential TB exposure risk to residents.   Findings include: 1. A review of E3’s personnel record revealed evidence of documentation of a two-step, negative skin test for infectious tuberculosis (TB). However, E3's evidence of documentation of a baseline assessment for signs and symptoms of, and risk of exposure to TB, as required in R9-10-113(B)(1), was unavailable for review.   2. In an interview, E1 agreed E3’s personnel record did not include documentation of freedom from infectious TB as required. E1 acknowledged the facility failed to ensure a caregiver who was expected to have more than eight hours of direct interaction with residents per week provided evidence of freedom from infectious TB as required.”

“Based on documentation review, record review, and interview, the manager failed to implement policies and procedures to cover in-service education for employees for one of two employees sampled. Findings include: 1. A review of the facility's policy and procedure manual, reviewed January 15, 2020, revealed a policy covering inservice education for employees which indicated employees were required to receive six hours of continuing education every calendar year. 2. A review of E3's (hired November 2019) personnel record revealed evidence E3 received five hours of continuing education 2022. Evidence E3 received any continuing education in 2023 was unavailable for review. 3. In an interview, E1 acknowledged E3's personnel record did not contain at least six hours of in-service education in 2022.”

“Based on document review and interview the manager failed to ensure that policies and procedures were reviewed at least once every three years. Findings include: 1. A review of the facility's policy and procedure manual, indicated it was reviewed January 15, 2020. 2. In an interview E1 reported the facility policies and procedures are updated individually throughout the year, however E1 acknowledged the policies and procedures had not been reviewed as a whole every three years as required.”

“Based on document review, record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and 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 current service plan indicating R1 received directed care services. A review of R2's medical record revealed a current service plan indicating R2 received personal care services. R1's and R2's service plan indicated each resident was to receive the service "Showering, Set-up, Standby Assist, 2x per week," "Basic Skin Care Do skin checks with each shower...Check for dry skin daily and moisturize..." and "Offer at least 1 glass of liquid to drink at every meal." 2. A review of R1's and R2's medical records revealed a document titled, "Caregiver ADL Checklist," dated September 2023, used for documenting services provided and activities of daily living. The documents included a section titled, "Grooming," which included bathing, skin check and apply lotion, as well as a section titled, "Food & Fluids" to document the respective services. Evidence the services were provided on September 9, 20, 28 or 29, 2023 was unavailable for review. 3. In an interview, E1 acknowledged evidence R1 and R2 were provided services and documented as described in R1's and R2's service plan was unavailable for review.”