Senita Ridge.

“Based on documentation review, record review, and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk as the facility was unaware of the general or specific whereabouts of a resident and the resident eloped from the facility.   Findings include:   1. A review of Department documentation revealed the facility was authorized to provide directed care services.   2. A review of R2's medical record revealed a document titled "Resident Incident Report" dated August 5, 2025. This document stated "On 8/5/25 around 10:03pm Peoria Police Officer...notified the facility that resident [R2] was found wandering on 91st Ave and Lake Pleasant Pkwy around 8:87PM (sic)..The officer called EMS due to residents current condition and symptoms and resident was transported to Arrowhead Hospital...Hospital dx dehydration, dementia, heat stress, pneumonia..." 3. In an interview, E1 and E2 reported R2 eloped from the facility through the south side door. At the time of the elopement, the south door sounded, however staff did not respond. 4. A review of an internal investigation document revealed E4 reported E4 was in a resident's room administering medications around 7PM. E4 continued, E4 did not respond to the alarm because another resident told E4 that the alarm was malfunctioning from the day before and didn't respond. E4 also reported that E4 asked caregivers to check and make sure all of the residents were in bed.    5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review, interview, and documentation review, the manager failed to ensure a personnel record for each caregiver included documentation of cardiopulmonary resuscitation (CPR) training, which included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of two employees reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.   Findings include:   1. A review of E3's personnel record revealed a CPR card that was obtained from "NationalCPRFoundation" issued on January 22, 2025. There was no other current documentation of CPR training available for review that included a demonstration of E3's ability to perform CPR.     2. In an email exchange, a representative from NationalCPRFoundation stated, "Our courses are online only."   3. A documentation review revealed the employee schedule, dated from January 21, 2025 to July 29, 2025, showed E3 had worked the following days: -January 21st, 23rd, 29th; -February 3rd, 5th, 6th, 8th, 11th, 20th, 26th, 27th; -March 5th, 6th, 26th, 27th; -April 2nd, 3rd, 4th, 9th, 10th, 21st, 23rd, 24th, 25th, 28th, 30th; -May 1st, 5th, 7th, 8th,12th, 22nd, 28th, 29th; -June 4th, 5th, 11th, 12th, 23rd, 25th, 26th, 27th, 30th; and -July 2nd, 3rd, 4th, 9th, 10th, 13th, 23rd, 24th, and 25th.   4. In an interview, E2 reported that E2 was unaware that online classes were not acceptable.   5. In an interview, E2 stated that E3 covered the day shift and the night shift.   6. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: b. The level of service the resident is expected to receive;”

“C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 6. Documentation: a. Of the resident's weight, or b. From a medical practitioner stating that weighing the resident is contraindicated; and”

“C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 7. Coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan.”

“B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: a. Is administered by an individual under direction of a medical practitioner,”

“A. A manager shall ensure that: 10. Oxygen containers are secured in an upright position;”

“A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan that included the level of service the resident was expected to receive, for one of three residents sampled. Findings include: 1. A review of R6's medical record revealed a service plan dated November 18, 2024. There was no indication of whether R6 was at the supervisory, personal or directed level of care. 2. In an interview, E1 acknowledged R6's service plan did not include whether R6 was at the supervisory, personal or directed level of care.”

“Based on record review and interview, the manager failed to ensure the service plan for five of five sampled directed care residents included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated. Findings include: 1. A review of R1's medical record revealed a service plan dated October 31, 2024. R1's service plan did not include documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. A review of R2's medical record revealed a service plan dated September 27, 2024. R2's service plan did not include documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated. 3. A review of R3's medical record revealed a service plan dated July 19, 2024. R3's service plan did not include documentation of R3's weight or documentation from a medical practitioner stating weighing R3 was contraindicated. 4. A review of R4's medical record revealed a service plan dated September 27, 2024. R4's service plan did not include documentation of R4's weight or documentation from a medical practitioner stating weighing R4 was contraindicated. 5. A review of R5's medical record revealed a service plan dated March 27, 2024. R5's service plan did not include documentation of R5's weight or documentation from a medical practitioner stating weighing R5 was contraindicated. 6. In an interview, E1 acknowledged R1's, R2's, R3's, R4's, and R5's service plans did not include documentation of the residents' weight or documentation from a medical practitioner stating weighing the residents was contraindicated.”

“Based on record review and interview, the manager failed to ensure the service plan for five of five sampled residents who received directed care services included coordination of communications with the resident's representative, family members, or other individuals identified in the resident's service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated October 31, 2024 2021 indicating R1 received directed care services. R1's service plan did not include coordination of communication with R1's representative, family members, or other individuals identified in R1's service plan. 2. A review of R2's medical record revealed a service plan dated September 27, 2024 2021 indicating R2 received directed care services. R2's service plan did not include coordination of communication with R2's representative, family members, or other individuals identified in R2's service plan. 3. A review of R3's medical record revealed a service plan dated July 19, 2024 2021 indicating R3 received directed care services. R3's service plan did not include coordination of communication with R3's representative, family members, or other individuals identified in R3's service plan. 4. A review of R4's medical record revealed a service plan dated September 27, 20242021 indicating R4 received directed care services. R4's service plan did not include coordination of communication with R4's representative, family members, or other individuals identified in R4's service plan. 5. A review of R5's medical record revealed a service plan dated March 27, 2024 2021 indicating R5 received directed care services. R5's service plan did not include coordination of communication with R5's representative, family members, or other individuals identified in R5's service plan. 6. In an interview, E1 acknowledged R1's, R2's, R3's, R4's, and R5's service plan did not include coordination of communication with residents' representative, family members, or other individuals identified in residents' service plan.”

“Based on record review and interview, the manager failed to ensure medication administered to a resident was administered by an individual under the direction of a medical practitioner, for one of six sampled residents. The deficient practice posed a risk if services were provided by an unqualified individual. Findings include: 1. A review of R4's medical record revealed a service plan dated September 27, 2024, which reflected R4 received medication administration services. R4's November 2024 medication administration revealed medications were administered by various caregivers. 2. A review of R4's record included a document titled "Physician Plan of Care" dated January 11, 2024 reflected "Nursing to administer medications" signed by R4's primary care physician. 3. In an interview, E1 acknowledged R4's record did not have documentation R4 was administered medications by an individual under the direction of a medical practitioner.”

“Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. Findings include: 1. During the environmental tour of the facility, the compliance officer observed four oxygen tanks upright, but unsecured, in an office located behind the front desk. 2. In an interview, E1 acknowledged the oxygen containers were left unsecured.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents. Findings include: 1. During a facility tour of the directed care facility, the compliance officer observed three 18-liter containers of paint accessible in a kitchenette area with a locked door, however the toxic materials were accessible via an open counter space. 2. In an interview, E1 acknowledged the poisonous or toxic materials were stored in an area accessible to residents.”