Park Senior Villas at Houghton - Villa Bb

Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. A review of facility documentation revealed an incident report dated July 21, 2025. The report revealed R1’s representative contacted the facility on July 21, 2025 to advise R1’s credit card was used by someone believed to be a staff member. E1 met with police and confirmed the identity of E2 on a video using R1’s credit card. E2 was arrested and terminated from employment with the facility on July 21, 2025. 2. During the facility’s investigation of the incident, it was learned that R1 believed the credit card was given to E2 to purchase items for E2’s new home. 3. A review of R1’s medical record revealed R1 was receiving directed care services. 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 failed to ensure a policy and procedure was implemented to protect the health and safety of a resident that covered cardiopulmonary resuscitation (CPR) training for applicable employees including the method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's ability to perform CPR, for one of three personnel records reviewed. Findings include: 1. A review of the facilities policies and procedures revealed a policy titled “CPR & First Aid Policy & Procedures”. The policy stated, “To ensure all employees providing direct care to residents have the skills and training to provide CPR…”. The document further stated, “CPR… c. Includes a demonstration of the individual’s ability to perform CPR” … “3. The CPR … training cannot be done Online.” 2. A review of E5's personal record revealed no documentation of current CPR Training. The record included documentation of CPR training issued on September 30, 2024, by "NationalCPRFoundation," an online-only CPR training program. 3. In an interview, E1 acknowledged E5's personnel record did not include current documentation of CPR training which included a demonstration of the individual’s ability to perform CPR.

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. In an interview, E1 acknowledged foods requiring refrigeration had not been maintained at 41°F or below. E1 reported the refrigerator would be replaced.