Trustwell Living at Kingswood Place

Based on documentation review and interview, the manager failed to establish and document policies and procedures to cover methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. Findings include: 1. Review of Department documentation revealed the facility was authorized to provide directed care services. 2. Review of the facility's policy and procedure manual revealed no policy that covered the methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident, and the assisted living services that the assisted living facility was authorized to provide. 3. In an interview, E1 acknowledged that a policy was not available that covered the methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services that the assisted living facility was authorized to provide.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were implemented that ensure the safety of a resident who may wander. This deficient practice posed a risk to residents. Findings include: 1. A review of Department records revealed the facility was licensed to provide Directed Care Services. 2. The Compliance Officer observed multiple ambulatory residents. 3. A review of an incident report dated September 9, 2025, stated "at 5:32 pm the pager indicated exit door #3 alarm...staff ran to the door and found R2 returning to apartment...nothing was said and assumed the only one by the door and activated the alarm...alarm was reset. At approximately 6:15 pm a police officer showed up asking if we had a resident by the name of (R1)...staff confirmed...police officer said the resident was at the building located behind the facility with EMS...EMS took vital and all normal with no injuries. Was returned back to the community and the incident was reported". 4. In an interview, E1 reported that the exterior door contained an alarm. However, staff did not follow policy by checking inside and outside to ensure no residents exited the building. E1 acknowledged the policy was not followed and indicated all staff were re-trained on the policy.

Based on record review, documentation review, and interview, the manager failed to establish and document policies and procedures for administering an opioid to protect the health and safety of a patient in compliance with R9-10-120.F. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. Review of R2’s medical record revealed an order for Tramadol HCL 50 MG 2 tablets by mouth twice a day for other chronic pain. There was no documentation of R2’s need for the opioid or how the opioid was monitored. R2 was not receiving end-of-life care or had an active malignancy. 2. Review of the facility’s policy and procedures revealed a policy titled “Controlled Drugs (Including Opioids), Management Policy,” which did not include the procedure for how, when, and by whom a patient’s need for opioid administration was assessed, how, when, and by whom a patient receiving an opioid was monitored, and cover how, when, and by whom the actions taken will be documented. 3. In an interview, E5 reported the facility records the resident's pain level before and the effectiveness after when the opioid was administered on an as needed basis. E5 reported the facility does not record opioid effectiveness for a scheduled opioid. 4. In an exit interview, the findings were reviewed with E1 and E5 and no additional information was provided.

Based on record review and interview, the manager failed to ensure the health, safety, or welfare of a resident. The deficient practice posed a health and safety risk to a resident. Findings include: 1. Review of R2’s medical record revealed an incident report dated July 10, 2025. The incident report stated, “[R2] was being taken to an appt. by van driver…” The report continued on, “As driver turned into a parking space resident fell off the seat onto the floor. Van driver then realized that resident [R2] was not buckled into [R2’s] seat belt. Resident hit [R2’s] head on the back of the seat and scraped [R2’s] left elbow.” 2. In an interview, R2 reported R2 did not put on the seat belt even when R2 was told. R2 reported R2’s fingers were numb and did not have the dexterity to put the seat belt on. R2 also reported R2 hit R2’s head. 3. In an interview, E1 acknowledged R2 suffered an injury during transport and that the health, safety, or welfare of the resident was not ensured. 4. In an exit interview, the findings were reviewed with E1 and E5 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures, for one of four caregivers reviewed. The deficient practice posed a health and safety risk. Findings Include: 1. Review of the facility’s policies and procedures revealed a policy titled, "Orientation and training policy” which stated, “Competency skills check lists are also completed for individuals responsible for the provision of resident care, health services, or medication assistance or administration. 2. Review of E2’s personnel record revealed E2 worked as a caregiver and had a hire date of May 19, 2025. E2’s record included a job description which stated, “6. Assist residents with daily bath, dressing, grooming, dental care, bowel and preparation for activities within the community…” 3. Review of E2’s personnel record revealed no documentation of a competency skills checklist as required by policy. 4. In an interview, E1 acknowledged E2's personnel record did not include a competency skills checklist for daily bath, dressing, grooming, dental care, and bowel care. 5. In an exit interview, the findings were reviewed with E1 and E5 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for two of four residents reviewed. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. Review of R1’s medical record revealed no documentation of assessing risks of prior exposure to infectious TB, a determination if R1 had signs or symptoms of TB, or documentation of freedom from infectious TB. Based on R1’s date of admission, this documentation was required. 3. Review of R2’s medical record revealed no documentation of assessing risks of prior exposure to infectious TB, a determination if R2 had signs or symptoms of TB, or documentation of freedom from infectious TB. R2's record did have a chest x-ray; however, documentation was not available, indicating R2 had a previous positive TB skin test or blood test, and without such documentation, a chest x-ray was not acceptable as documentation of freedom from TB. Based on R2’s date of admission, this documentation was required. 4. In an exit interview, the findings were reviewed with E1 and E5 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure policies and procedures were developed that included an evaluation of the resident before and after the transport. The deficient practice posed a health and safety risk to a resident. Findings include: 1. Review of R2’s medical record revealed an incident report dated July 10, 2025. The incident report stated, “[R2] was being taken to an appt. by van driver…” The report continued on, “As driver turned into a parking space resident fell off the seat onto the floor. Van driver then realized that resident [R2] was not buckled into [R2’s] seat belt. Resident hit [R2’s] head on the back of the seat and scraped [R2’s] left elbow.” However, there was no documentation of patient evaluation before and after transportation. 2. In an interview, R2 reported R2 did not put on the seat belt even when R2 was told. R2 reported R2’s fingers were numb and did not have the dexterity to put the seat belt on. R2 also reported R2 hit R2’s head. 3. Review of the facility’s policies and procedures revealed that there was no policy on evaluations for transport. 4. In an interview, E1 reported R2 was being transported to a doctor's appointment and acknowledged there was no policy for evaluation of a resident before and after transportation. 5. In an exit interview, the findings were reviewed with E1 and E5 and no additional information was provided.