A Place All My Own - Paradise

Based on record review and interview, the administrator did not ensure a comprehensive assessment of a resident was updated no later than 12 months after the date of the resident's last comprehensive assessment for one of two residents sampled. Findings include: 1. A review of R1's and R2's medical record revealed comprehensive assessment dated September 17, 2024. However, no further comprehensive assessments were available for review. 2. In an interview, E1 acknowledged a comprehensive assessment of R1 was not updated no later than 12 months after the date of R1's and R2's last comprehensive assessment.

Based on documentation review and interview, the administrator did not ensure policies and procedures for medication administration were reviewed and approved by a pharmacist. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Medication Administration.” However, the policy did not include documentation of having been reviewed and approved by a pharmacist. 2. In an interview, E1 acknowledged the policies and procedures for medication administration were not reviewed and approved by a pharmacist.

Based on documentation review and interview, the administrator did not ensure 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 facility documentation revealed no documentation of a disaster drill for employees conducted was available for review. 2. In an interview, E4 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.