A Paradise for Parent's Senior Living LLC

Based on record review, documentation review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver received orientation that was specific to the duties to be performed, for two of two employees sampled. The deficient practice posed a risk if the employee was unable to meet the needs of a resident. Findings include: 1. Review of E2’s personnel record revealed a hire date of June 30, 2019. The personnel record did not include documentation of orientation that was specific to the duties to be performed. 2. Review of E3’s personnel record revealed a hire date of April 26, 2025. The personnel record did not include documentation of orientation that was specific to the duties to be performed. 3. Review of the facility’s policies and procedures revealed a policy titled, “All employees and Volunteers” which stated, “1) It is required that each employee and volunteer receives orientation before providing assisted living services to the resident.” 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided to the resident, for one of two residents sampled. The deficient practice posed a risk as the service plans did not reinforce and clarify the services to be provided to a resident. Findings include: 1. Review of R1’s current service plan dated August 4, 2025, revealed there was a check mark for the following services: - “teeth hair groom” and there was a check mark by “CG assist”; - “CG assist w/ dressing”; and - “Bathe” and there was a check mark by “CG assist w skin checks”. The frequency was not indicated for these services. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, record review, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, which provided access to a secured outside area that monitored or alerted employees of the resident’s egress from the facility. This deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Review of Department documentation revealed the facility is licensed to provide directed care services. 2. The Compliance Officer observed ambulatory residents. The Compliance Officer observed R2 wander to the backyard and was escorted back into the facility by caregivers. 3. The Compliance Officer observed the alarm to the back door was turned off. When the door was opened, it did not alert of egress. The door had deadbolt locks, which did not require a key to use. The caregiver turned back on the alarm and when the door opened, it alerted of egress. 4. Review of the facility policy and procedures revealed a policy titled, “Wandering Residents Safety,” which stated, “If alarms are being used on doors and/or windows, the caregiver will check them daily for operational and security.” 5. Review of R2’s medical record revealed a document titled “Incident Report”, which stated, “Resident snuck out of house, fire department took [R2] to hospital just in case.” Under the section titled “Action taken by the home to prevent reoccurrence," it stated, “got louder alarm of the front door + head counts more often.” 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the following in an unlocked cabinet under the kitchen sink: Lysol all-purpose cleaner Dawn dish soap Platinum Cascade dishwasher detergent 2. During the environmental inspection of the facility, the Compliance Officer observed the following in the unlocked laundry room: Three Arm and Hammer OxiClean detergent containers Pledge floor care Two Clorox spray bottles Three Lysol all-purpose cleaners 3. The Compliance Officer observed in a resident’s closet one bottle of Nature’s Miracle Urine Destroyer. 4. Review of the facility's policy and procedures revealed a policy titled, “Emergency, Safety, and Environmental," which stated, “ 7) Poisons and toxic material materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas.” 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, interview, documentation review, and record review, the manager failed to ensure a personnel record was established and maintained for each employee as required. The deficient practice posed a risk as required information could not be verified for E1 and E2. Findings include: 1. When the Compliance Officers arrived at the facility, E1 and E2 were observed at the facility. 2. In an interview, E1 and E2 were hired as caregivers identifying May 2, 2024, as their first day of work at AL10123. 3. A review of the facility's policies and procedures signed February 15, 2024, revealed a policy titled "Qualifications Caregivers, Assistant Caregiver and Volunteers." The policy stated "5) A manager shall ensure that a personnel record for a personnel member, employee, volunteer, or student include: full name, date of birth, current address and phone number, date of hire, work experience and references..." An additional policy titled "Orientation and in-service training" stated "New employee orientation is required to be completed by all new employees before starting to provide assisted living services to the residents..." 4. A review of E1's personnel file revealed no documentation of E1's date of employment, contact telephone number, verification of skills and knowledge, orientation, work experience and references. 5. A review of E2's personnel file revealed no documentation of E2's date of employment, contact telephone number, verification of skills and knowledge, orientation, work experience and references. 6. In an interview, E7 reviewed E1 and E2's personnel record. E1 acknowledged the identified documents were missing from E1 and E2's personnel record for AL10123. 7. In an interview, E2 reported E4 provided E2 orientation to the facility the previous day. However no documentation of the orientation was available for review. 8. In a phone interview, E3 acknowledged personnel records were not fully established for E1 and E2.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for one of two residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. Review of R1's medical record revealed a current written service plan for personal care services dated April 25, 2024. However, the service plan did not include a signature and date from the resident or representative. 2. In an interview, E7 acknowledged R1's service plan did not include a signature and date from the resident or representative.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for two of two residents reviewed. Findings include: 1. A review of facility documentation revealed R2's Medication Administration Record (MAR) dated May 2024. The MAR revealed no documentation R1 received medication administration on May 1, 2024. A review of R1's medication record revealed medication orders for the following medications; Metoprolol 25 mg take one tab PO BID, and Lisinopril 20 mg take one tab PO QD. 2. A review of R1's medications revealed the identified medications were available. 3. In an interview, E4 reported E4 administered the medications to R1 on May 1, 2024. E4 acknowledged E4 did not document the administration of the medication in R1's medical record for the date identified.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. Review of the May 2024 personnel schedule revealed two shifts; 7am-730 pm and 7pm-730 am. 2. Review of the facility's employee disaster drills revealed the following drills; March 1, 2024, at 9:10 am March 2, 2024, at 6:03 pm March 4, 2024, at 3:15 pm December 1, 2023, at 8:45 am December 5, 2023, at 5 pm December 2, 2023, at 8 pm September 1, 2023, at 9:15 am September 2, 2023, at 4:30 pm September 4, 2023, at 7 pm June 1, 2023, at 9:15 am June 5, 2023, at 6:30 pm 3. In an interview, E7 acknowledged the employee disaster drills were not conducted on each shift at least once every three months.