Paradise Life Care 2

Based on record review and interview, the manager failed to ensure a resident's written service plan included the frequency of assisted living services being provided to the resident, for two of two residents reviewed. 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. A review of R1's and R2's medical records revealed current service plans. However, the service plans revealed the following: R1's service plan, December 2025, did not include the frequency of assistance with dressing, bathing, or showering, grooming, incontinence care, and medication administration. R2's service plan dated November 2025, did not include the frequency of assistance with dressing, bathing, or showering, grooming, medication administration, and Foley catheter care. 2. In an interview, E1 acknowledged that the service plans did not include the frequency of services for R1 and R2. 3. In an exit interview, the findings were reviewed with E1 and E2, 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 two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, dated December 2025, for directed care services. However, the service plan had not been signed and dated by the resident or resident's representative. 2. A review of R2's medical record revealed a service plan, dated November 2025, for directed care services. However, the service plan had not been signed and dated by the resident or resident's representative. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated July 7, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated May 31, 2023. This medication order stated "Eliquis 2.5mg 1 tab BID PO". 3. Review of R1's medical record revealed a July 2023 medication administration record (MAR). This MAR stated "Eliquis 2.5mg 1 tab PO BID" and indicated one tab was administered at 8am and 8pm July 1st - present. 4. During an observation of R1's medications, Eliquis 2.5mg was not observed. 5. In an interview, E2 reported the medication ran out approximately four days ago. E1 and E2 acknowledged R1's medication was not administered in compliance with the available medication order.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as the medical record inaccurately indicated a medication was administered, and the Department was provided false and misleading information. Findings include: 1. Review of R1's medical record revealed a current written service plan dated July 7, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated May 31, 2023. This medication order stated "Eliquis 2.5mg 1 tab BID PO". 3. Review of R1's medical record revealed a July 2023 medication administration record (MAR). This MAR stated "Eliquis 2.5mg 1 tab PO BID" and indicated one tab was administered at 8am and 8pm July 1st - present. 4. During an observation of R1's medications, Eliquis 2.5mg was not observed. 5. In an interview, E2 reported the medication ran out approximately four days ago. E1 and E2 acknowledged R1's medical record inaccurately indicated a medication was administered.