My Parents Paradise at Montoro Preserve

Based on observation and interview, the manager failed to ensure there was a means of exiting the facility which controlled 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 general or specific whereabouts of a resident. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed the front door leading to the front yard. The door had an alert and no control. However, the alert was not functional at the time of inspection. 2 . In an interview, E1 acknowledged the front door alert was not functional.

Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least once every 12 months. Findings include: 1 . A review of facility documentation revealed documentation of an annual disaster plan review for 2021, 2022, and 2025. However, annual disaster plan reviews for 2023 and 2024 were not available for review at the time of inspection. 2 . In an interview, E1 acknowledged the disaster plan annual reviews for 2023 and 2024 were not available for review at the time of inspection.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a cabinet in a common bathroom under the sink with no locking mechanism. Inside the cabinet was a bottle of "Oxi-Clean" stain remover and a can of "Raid" ant killer. 2 . During an environmental inspection of the facility, the Compliance Officer observed a cabinet under the kitchen sink. The cabinet had a magnetic lock, but the lock was disengaged. Inside the cabinet was the following: -Two jugs of "Fabuloso" multi-purpose cleaner; -A bottle of "Oxi-Clean' stain remover; and -A can of "Raid" ant killer. 3 . In an interview, E1 acknowledged toxins were not kept inaccessible to residents.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident to cover termination of residency, including termination initiated by the manager of an assisted living facility. Findings include: A.A.C. R9-10-807(G)(2) A manager may terminate residency of a resident as follows: With a 14-calendar-day written notice of termination of residency: a. For nonpayment of fees, charges, or deposit; or b. Under any of the conditions in subsection (C). A.A.C. R9-10-807(C)(2)(3) C. A manager shall not accept or retain an individual if: The primary condition for which the individual needs assisted living services is a behavioral health issue; The services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual. 1. A review of the facility's policies and procedures revealed a policy titled, "Resident rights, acceptance, and termination" (effective date March 17, 2020). The policy stated, "... ..."11. The facility manager may terminate the residency of a resident if any of the following ...With a 14 day notice of termination of residency if any of the following...2. The assisted living services needed by the individual are not within the assisted living facility's scope of services. 3. The assisted living facility does not have the ability to provide the assisted living services needed by the individual ..." The manager established and documented a policy and procedure which allowed the manager to terminate the residency of a resident in a manner contrary to R9-10-807(G). 2. In an interview, E1 acknowledged this policy and procedure allowed termination of residency in a manner contrary to R9-10-807(G). Technical assistance was provided on this Rule during the compliance inspection conducted on April 29, 2022.

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 and if an individual was requesting or was expected to receive supervisory care services, personal care services, or directed care services included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; and dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a document titled "Consent for Resident's Stay In My Parent's Paradise Facility" (dated April 20, 2023). However, the document was not dated within 90 calendar days before R1 was accepted by the assisted living facility. 2. A review of R2's medical record revealed a document titled "Consent for Resident's Stay In My Parent's Paradise Facility" (dated October 8, 2022). However, the document was not dated within 90 calendar days before R2 was accepted by the assisted living facility. 3. In an interview, E1 reported R1 and R2 were expected to receive directed care services. E1 indicated the documentation dated within 90 calendar days before R1 was accepted by the facility may have been misfiled. E1 did not respond when given the opportunity to explain why R2 submitted documentation not dated within 90 calendar days before R2 was accepted.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and controlled or alerted employees 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 an alert system was installed on the patio door leading to the backlyard. The Compliance Officer observed when exiting from the patio door to the backyard, no alarm sounded to alert employees of the egress of a resident from the facility as the alert system was not functioning. 3. In an interview, E1 acknowledged the patio door did not alert employees of the egress of a resident from the facility. E1 reported to turn the alert system on every day. E1 indicated the residents may turn it off as it annoys them. E1 believed the current residents were safe without the alert system due to their ability to acknowledge the presence of danger. Technical assistance was provided on this Rule during the compliance inspection conducted on April 29, 2022.