Paseo Village.

“Based on record review and interview, the manager failed to ensure that a resident’s medical record contained the document signed by the resident consenting for the resident’s representative to act on the resident’s behalf or a copy of the health care power of attorney, for one of ten residents sampled.  Findings include:  1. Review of R3’s medical record revealed R3’s current service plan dated September 2025. The service plan revealed R3 received a directed level of care.  2. Review of R3’s medical record revealed R3’s service plan was signed by another person.  3. In an interview, E1 acknowledged there is no documentation to show R3 has consented to have a power of attorney or a resident representative to sign for R3. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on interview, the manager failed to ensure a resident was treated with dignity, respect and consideration. Findings include: 1. A review of the facility's policy and procedures revealed a document titled "Standing Policies For All Unit Resident and Staff" updated February 4, 2025 which reflected "During the first 30 days after admission, residents are not allowed to leave the unit or go on passes unless otherwise specified in the Behavioral Care Plan (BCP) ... 2. Smoking. Residents may smoke cigarettes according to the following guidelines: Residents may not carry their own cigarettes ... 5. Meals In The Dining Room: No food is to be brought out of the dining room; Residents will have 45 minutes after the meal is served to eat ... 7. Meals ... Food Delivery services (e.g. Uber Eats, Door Dash, Pizza Delivery) will not be permitted for residents in the program ... Telephone Calls ... Maximum time for telephone calls (outgoing and incoming) is 10 minutes except when talking to case manager, clinical professional, legal representative, or advocacy organizations ...If a resident makes a call in it does not go through or go to voicemail they may attempt to make one an d only one more call ... Residents may not have a cell phones on the unit ... 11. Money ... Residents may not have money, credit cards/debit cards in their possession while on the unit unless specified in their Behavioral care plan.. Televisions and Radios ... Movies and TV shows played privately in residents' rooms are to be determined on a caser-by-case basis depending on the resident. The med tech is to make the final decision as to whether or not a movie/show is appropriate for the resident in question .... 16. Personal Computers, Tablets, Cell Phones ... Residents are not permitted the use of their own personal computers, tablets or cell phones while residing on the unit." 2. In an interview, E1 and E2 confirmed each resident must abide by the above rules of the program. E1 and E2 confirmed each resident must sign and agree to the above rules to resident at the facility. 3. In an interview, R3 reported not being able to go to visit family during the holidays, and was not allowed to have a cell phone and has not been allowed to order outside food since residing at the facility. 4. In an interview, R3 reported the facility stores and distribute R3's cigarettes. R3 reported sometimes R3's cigarette breaks were sometimes taken away and has been told to leave the designated smoking area during designated smoke break times while other residents were allowed to smoke. R3 reported the facility's staff is in possession of R3's cigarettes. 5. In an interview, E4 reported attempting to collaborate with R3's representative regarding establishing court order treatment for R3 due to R3's medication refusal, behaviors and "Psych". 6. A review of the facility's documentation, revealed and email correspondence dated November 27, 2024, which reflected R3's representative would be referred to adult protective services if R3 was taken out of the facility for a visit. 7. In an interview, E1 clarified APS would be notified of an unsafe discharge of R3 if R3's representative would've picked up R3 for an off-site visit due to R3 having behaviors.”

“B. A manager shall ensure that: 2. A resident is not subjected to: d. Coercion;”

“Based on documentation review and interview, for four of four sampled residents reviewed, the manager failed to ensure a resident received assisted living services that supported and respected the resident's individuality, choices, strengths, and abilities Findings include: 1. A review of the facility's policy and procedures revealed a document titled "Standing Policies For All Unit Resident and Staff" updated February 4, 2025 which reflected "During the first 30 days after admission, residents are not allowed to leave the unit or go on passes unless otherwise specified in the Behavioral Care Plan (BCP) ... 2. Smoking. Residents may smoke cigarettes according to the following guidelines: Residents may not carry their own cigarettes ... 5. Meals In The Dining Room: No food is to be brought out of the dining room; Residents will have 45 minutes after the meal is served to eat ... 7. Meals ... Food Delivery services (e.g. Uber Eats, Door Dash, Pizza Delivery) will not be permitted for residents in the program ... Telephone Calls ... Maximum time for telephone calls (outgoing and incoming) is 10 minutes except when talking to case manager, clinical professional, legal representative, or advocacy organizations ...If a resident makes a call in it does not go through or go to voicemail they may attempt to make one an d only one more call ... Residents may not have a cell phones on the unit ... 11. Money ... Residents may not have money, credit cards/debit cards in their possession while on the unit unless specified in their Behavioral care plan.. Televisions and Radios ... Movies and TV shows played privately in residents' rooms are to be determined on a caser-by-case basis depending on the resident. The med tech is to make the final decision as to whether or not a movie/show is appropriate for the resident in question .... 16. Personal Computers, Tablets, Cell Phones ... Residents are not permitted the use of their own personal computers, tablets or cell phones while residing on the unit." 2. In an interview, E1 and E2 confirmed each resident must abide by the above rules of the program. E1 and E2 confirmed each resident must sign and agree to the above rules to resident at the facility. 3. In an interview, R3 reported not being able to go to visit family during the holidays, and was not allowed to have a cell phone and has not been allowed to order outside food since residing at the facility. 4. In an interview, R3 reported the facility stores and distribute R3's cigarettes. R3 reported sometimes R3's cigarette breaks were sometimes taken away and has been told to leave the designated smoking area during designated smoke break times while other residents were allowed to smoke. R3 reported the facility's staff is in possession of R3's cigarettes. 5. In an interview, E4 reported attempting to collaborate with R3's representative regarding establishing court order treatment for R3 due to R3's medication refusal, behaviors and "Psych". 6. A review of the facility's documentation, revealed and email correspondence dated November 27, 2024, which reflected R3's representative would be referred to adult protective services if R3 was taken out of the facility for a visit. 7. In an interview, E1 clarified APS would be notified of an unsafe discharge of R3 if R3's representative would've picked up R3 for an off-site visit due to R3 having behaviors.”

“Based on documentation review and interview, for four of four sampled residents reviewed, the manager failed to ensure residents receive privacy in financial and personal affairs. A review of the facility's policy and procedures revealed a document titled "Standing Policies For All Unit Resident and Staff" updated February 4, 2025 which reflected "During the first 30 days after admission, residents are not allowed to leave the unit or go on passes unless otherwise specified in the Behavioral Care Plan (BCP) ... 2. Smoking. Residents may smoke cigarettes according to the following guidelines: Residents may not carry their own cigarettes ... 5. Meals In The Dining Room: No food is to be brought out of the dining room; Residents will have 45 minutes after the meal is served to eat ... 7. Meals ... Food Delivery services (e.g. Uber Eats, Door Dash, Pizza Delivery) will not be permitted for residents in the program ... Telephone Calls ... Maximum time for telephone calls (outgoing and incoming) is 10 minutes except when talking to case manager, clinical professional, legal representative, or advocacy organizations ...If a resident makes a call in it does not go through or go to voicemail they may attempt to make one an d only one more call ... Residents may not have a cell phones on the unit ... 11. Money ... Residents may not have money, credit cards/debit cards in their possession while on the unit unless specified in their Behavioral care plan.. Televisions and Radios ... Movies and TV shows played privately in residents' rooms are to be determined on a caser-by-case basis depending on the resident. The med tech is to make the final decision as to whether or not a movie/show is appropriate for the resident in question .... 16. Personal Computers, Tablets, Cell Phones ... Residents are not permitted the use of their own personal computers, tablets or cell phones while residing on the unit." 2. In an interview, E1 and E2 confirmed each resident must abide by the above rules of the program. E1 and E2 confirmed each resident must sign and agree to the above rules to resident at the facility.”

“Based on interview, record review, and documentation review, the manager failed to ensure a resident had the right to choose to access services from a health care provider, health care institution, or pharmacy other than the assisted living facility where the resident is residing and receiving services or a health care provider, health care institution, or pharmacy recommended by the assisted living facility. Findings include: 1. In an interview, E4 reported attempting to collaborate with R3's representative regarding establishing court order treatment for R3 due to R3's medication refusal, behaviors and "Psych". 2. A review of R3's medical record revealed a document titled "Observation" December 5. 2024 "Care plan meeting was attended today by [E1], [E2], [R3's case manager], [clinical director]. [R3's representative] did not show up, ED called [R3's representative]and left a voicemail. Care was talked about by those who attended, [R3] has refused medications the past few days provider was notified, intervention in place by [E4], do to past history of psych and COT (court ordered treatment) possibility of petitioning was mentioned if behaviors continues and present danger to self or others. 3. In an interview, R3 reported refusing to visit with E4, but was required to by the facility. 4. A review of the facility's documentation, revealed and email correspondence dated November 27, 2024, which reflected R3's representative would be referred to adult protective services if R3 was taken out of the facility for a visit. 5. In an interview, E1 clarified APS would be notified of an unsafe discharge of R3 if R3's representative would've picked up R3 for an off-site visit due to R3 having behaviors, and the visit was not approved by E4.”

“Based on record review and interview, the manager failed to ensure a resident's medication was administered in compliance with a medication order for one of ten residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R7's medical record revealed R7 received medication administration. 2. A review of R7's medical record revealed a signed medication order dated November 9, 2023 for Quetiapine 50 MG two times a day. 3. A review of R7's medical record revealed a medication administration record (MAR) which indicated Quetiapine 50 MG was not administered on the following dates and times: - September 15, 2024 at 8am and 8pm - September 16, 2024 at 8am 4. A review of the MAR notes on September 15th and 16th revealed "Medication not in cart, contact pharmacy". 5. In an interview, E1 acknowledged R7's medication was not available and not administered as ordered.”

“Based on record review and interview, the manager failed to ensure a written service plan included the amount, type, and frequency of assisted living services provided for one of six residents reviewed. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. Review of R1's medical record revealed a written service plan dated August 18, 2023. This service plan indicated R1 had a foley catheter, however did not indicate the amount, type, and frequency of the catheter care. 2. In an interview, E1 acknowledged R1's service plan did not include the amount, type, and frequency of assisted living services provided to R1.”