The Villas at Benson VII

The facility failed to ensure that one of three sampled residents was tested for tuberculosis disease upon admission. A review of Resident #1's records showed no documentation of any TB skin tests despite the resident being admitted in March 2022.

The facility failed to ensure that one of three sampled residents was tested for tuberculosis (TB) disease upon admission. While a chest X-ray was available, there was no documentation of a TB skin test or a history of a positive TB skin test for the resident.

The facility failed to implement CDC recommendations regarding source control during the COVID-19 pandemic. Specifically, the Resident Care Director was observed not wearing a facemask while inside the facility, failing to maintain necessary universal source control measures.

The facility failed to implement and maintain CDC-recommended infection prevention practices during the COVID-19 pandemic. Specifically, the Resident Care Director was observed not wearing a facemask while inside the facility, despite guidance stating that universal source control measures should be maintained regardless of vaccination status.

The facility failed to ensure sufficient awake staff were on duty to meet the supervision needs of residents who were constantly disoriented. Specifically, a live-in medication aide worked alone and was allowed to sleep at night, despite residents having a history of exiting the building at night to smoke.

The facility failed to employ sufficient staff to meet the supervision needs of residents who were disoriented. Specifically, staff were not awake or available to monitor two residents, one of whom frequently exited the building at night to smoke without alerting staff.