Villas at King Road, the, Villa B

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.