Jane's Place.

“Based on documentation review, record review, and interview, the manager failed to ensure that a resident had a service plan that was reviewed and updated at least once every three months for a resident receiving directed care services. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "Services", which stated: "The Management will ensure each resident's service plan is completed no later than 14 days after the resident's date of acceptance and is updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition; and accordingly with the level of care: every 12 months for residents receiving supervisory care services, every 6 months for residents receiving personal care services or every 3 months for residents receiving directed care services." 2. A review of R1's medical record revealed a service plan showing the directed level of care and last updated on October 07, 2025. 3. In an interview, the findings were reviewed with E1, and no additional documentation was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "Medication Services", which stated: "A medication administered to a resident a. Is administered by an individual under direction of a Medical Practitioner b. Is administered in compliance with a medication order c. Personnel, moves the medication from the container or medication organizer and places in cup or resident's hand d. Observing the resident while the resident takes the medication e. Is documented in the resident's MAR" 2. A review of R1's medical record revealed R1 requires medication administration and medication orders. A review of R1's April 2026 medication administration record (MAR) revealed no documentation for the following medication: Allopurinol 100MG take 1 tablet by mouth once daily: 6th Omeprazole 20MG take 1 capsule by mouth once daily: 6th Quetiapine 100 MG take 1 tablet by mouth once daily: 3rd and 6th Acetaminophen 325MG take 2 tablets by mouth twice a day: 1st, 2nd, 3rd, 5th and 6th Melatonin 10MG Take 1 capsule by mouth at bedtime for Insomnia: 1st, 2nd, 3rd, 5th and 6th Pravastatin Sodium 40MG Take 1 tablet by mouth at bedtime: 1st - 6th Trazodone 50MG Take 2 tablets by mouth at bedtime: 1st - 6th 3. A review of R2's medical record revealed R2 requires medication administration and medication orders. A review of R2's April 2026 MAR revealed no documentation for the following medication: Carvedilol 3.125MG take 1 tablet by mouth twice daily: 1st - 6th Divalproex Delayed 125MG take 1 tablet by mouth twice daily. Take second dose 8 hours apart: 1st - 6th Metformin HCL 500MG take 1 tablet by mouth twice daily: 1st - 6th Quetiapine 50MG take 1 and 1/2 tablets(75mg) by mouth twice daily: 1st - 6th Ranolazine ER 500MG take 1 tablet by mouth twice daily: 1st - 6th Tamsulosin HCL 0.4 MG take 1 capsule by mouth once daily in the evenings: 1st - 6th Atorvastatin 40MG take 1 tablet by mouth at bedtime: 1st - 6th Trazodone 100MG take 1 tablet by mouth at bedtime: 1st - 6th 4. In an interview, E1 reported that medication was provided. 5. In an interview, the findings were reviewed with E1, and no information was provided regarding the findings.”

“Based on documentation review, observation, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "Security and Safety", which stated: "A Manager shall maintain environmental safety on the premises. Equipment used at the assisted living facility are kept safe from a condition that may cause a resident or individual to suffer physical injury or illness. " 2. During an environment inspection of the backyard, the Compliance Officer observed mattresses, bed railings, and wheelchairs in the patio area. The Compliance Officer also observed boxes stacked all the way up to the patio ceiling. Some boxes were stacked on top of mattresses. 3. During an environmental inspection of R2's and R3's room, the Compliance Officer observed a broken shelf with a piece of metal sticking out. 4. In an interview, E1 reported that someone was to pick up the old equipment, but they never came. 5. In an interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policy and procedure manual revealed documentation indicating the policies and procedures were reviewed by the manager on January 29, 2021. However, there was no signature or date to verify that the manager had reviewed and updated the policies and procedures within the required three-year timeframe. 2. During an interview, E2 and O1 acknowledged E1 failed to ensure policies and procedures were reviewed and updated at least once every three years.”

“Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility, for two of three sampled residents. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R1's medical record revealed a residency agreement. However, the residency agreement stated it was between R1 and a different assisted living facility, not " AL10372H_JANE'S PLACE." 2. A review of R3's medical record revealed a residency agreement. However, the residency agreement stated it was between R3 and a different assisted living facility, not " AL10372H_JANE'S PLACE." 3. In an interview, E2 and O1 acknowledged R1 and R3 did not have a residency agreement with this facility.”

“Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if facility staff were unaware of the egress of a resident from the facility. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed the door leading out to the backyard from bedroom 2. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. However, the door was not secured and the door chime was not functioning. 3. During the environmental tour, the Compliance Officer observed a door located in the kitchen leading to the back yard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. However, the door was not secured and the door chime was not functioning. 4. In an interview, E2 and O1 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.”