A Parent's Paradise LLC

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees 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 a disaster plan. Findings include: 1. A review of the facility's personnel schedule revealed there were two shifts. 2. A review of the facility's disaster drills revealed the last documented disaster drill was conducted on October 10, 2025 on both shifts. 3. In an interview, E2 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services included documentation of the resident’s weight or from a medical practitioner indicating that weighing the resident was contraindicated, for one of three residents sampled. Findings include: 1. A review of R1’s medical record revealed a service plan update dated January 2, 2026. However, R1’s service plan did not include R1’s weight or documentation from R1’s medical practitioner stating that weighing R1 was contraindicated. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's Disaster Relocation Plan revealed the disaster plan was last reviewed on January 1, 2025. 2. A review of the facility's policies and procedures revealed a policy that read "is reviewed and the review is documented at least once every 12 months..." 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a service plan was signed and dated by the resident or resident's representative when the service plan was initially developed or when updated, for one of three sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, dated January 2, 2026, for directed care services. However, the service plan had not been signed and dated by the resident or resident's representative. 2. In an exit interview with E2, the findings were reviewed and no additional information was provided.

Based on interview and documentation review, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident that cover methods by which an assisted living center 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 center was authorized to provide. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer requested to review the facility's policy and procedure 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. However, E1 was unable to locate the aforementioned policy and procedure for review. 3. In an interview, E1 reviewed the facility's policies and procedures, and acknowledged a policy was not documented 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 the assisted living facility was authorized to provide.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility, for one of two residents reviewed. The deficient practice posed a health and safety risk if the resident needed to exit the facility in an emergency. Findings include: 1. Review of R2's medical record revealed no documentation of orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility. Based on R2's date of acceptance, this documentation was required. 2. In an interview, E1 acknowledged documentation was not available showing R2 was oriented to the current facility's evacuation plan.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's record revealed a current written service plan for directed care services dated July 26, 2023. This service plan stated "check pressure areas and feet daily". However, documentation was not available indicating this service was provided September 1 - present. 2. In an interview, E1 acknowledged R1's medical record did not include documentation of the above listed service and reported the service was provided as indicated in the service plan.