Circle of Life Alzheimer Homes, LLC

Based on record review and interview, the manager failed to ensure a resident had a service plan that was established and documented that included the amount, type, and frequency of assisted living services being provided to the resident, for two of two sampled residents. The deficient practice posed a risk as a service plan guides a resident’s care. Findings include: 1. A review of R1's and R2’s medical records revealed documentation of assisted living services (ADLs) provided to R1 and R2 dated October 2025 and November 2025. The ADLs revealed R1 and R2 received assistance combing hair. However, R1’s and R2’s service plans did not include this service. The service plans further did not include medication services. 2. In an interview, E2 acknowledged the service plans did not include combing hair or medication services, including the frequency of both services. Technical assistance was provided on this rule during the compliance inspection conducted on September 7, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure 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 that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed a door leading from R3’s bedroom to the backyard. The Compliance Officer observed the door had an alert installed. However, the Compliance Officer observed the alert set to the “Off” position and upon opening the door, the Compliance Officer heard no alert. The Compliance Officer further observed no monitoring system in place. 3. In an interview, E2 reported R3 often turned off the alert or asked facility personnel to turn off the alert because the noise bothered R3.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by an assisted living facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for two of two total residents. Findings include: 1. A review of the medical records for R1 and R2 revealed no documentation dated within 90 calendar days before R1 and R2 were accepted by the assisted living facility to include whether R1 and R2 required continuous medical services, continuous or intermittent nursing services, or restraints. 2. In an interview, E4 reported not having the aforementioned documentation for R1 and R2. Technical assistance was provided on this rule during the compliance inspection conducted on April 27, 2022.