A Parent's Paradise LLC.

“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 one of three sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, dated January 2, 2026, for directed care services. However, the service plan had not been signed and dated by the resident or resident's representative. 2. In an exit interview with E2, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services included documentation of the resident’s weight or from a medical practitioner indicating that weighing the resident was contraindicated, for one of three residents sampled.  Findings include:  1. A review of R1’s medical record revealed a service plan update dated January 2, 2026. However, R1’s service plan did not include R1’s weight or documentation from R1’s medical practitioner stating that weighing R1 was contraindicated.  2. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure a disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's Disaster Relocation Plan revealed the disaster plan was last reviewed on January 1, 2025. 2. A review of the facility's policies and procedures revealed a policy that read "is reviewed and the review is documented at least once every 12 months..." 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan.   Findings include:   1. A review of the facility's personnel schedule revealed there were two shifts. 2. A review of the facility's disaster drills revealed the last documented disaster drill was conducted on October 10, 2025 on both shifts. 3. In an interview, E2 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.”

“Based on interview and documentation review, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident that cover methods by which an assisted living center was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living center was authorized to provide. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer requested to review the facility's policy and procedure to cover methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. However, E1 was unable to locate the aforementioned policy and procedure for review.   3. In an interview, E1 reviewed the facility's policies and procedures, and acknowledged a policy was not documented that covered the methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide.”

“Based on documentation review and interview, the facility failed to implement its policy and procedures for a documented report submitted to the governing authority. The deficient practice posed a risk if the facility did not accurately document a review of incidents, and provided false or misleading information to the Department.   Findings include:   1. In documentation review, the facility's policy titled "Quality Management Program," documented, "... In order to provide quality and safe services to the facility residents, the manager shall ensure that... Methods to evaluate the data collected to identify concerns about the delivery of services related to resident care are available as procedure below... At least every 6 months the manager will report to the governing authority/licensee all the concerns about the delivery of services related to residence care and any change made or action taken that has resulted in the identification of a concern about the delivery of services related to residence care. The manager will use the "Quality Management - Summary Form... for reporting." 2. In documentation review, the Compliance Officer requested to review the facility's QM reports, and was provided a facility report titled "Quality Management - Summary Form...," dated "Nov. 21, 2024 to May 21, 2025, and was signed by E2, and dated May 21, 2025. The report documented, "TO BE COMPLETED EVERY SIX MONTHS BY MANAGER OR MANAGER DESIGNEE AND PRESENTED TO THE GOVERNING AUTHORITY." 3. During an interview, E1 reported being confused about the due date of the QM report; however, acknowledged the current date was April 7, 2025, and the report was completed and dated through May 21, 2025, a future date.”

“Based on observation, documentation review, and interview, for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area 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. A review of the license issued by the Department revealed the facility was licensed at the directed care level.   2. The Compliance Officer observed a patio door to the backyard did not control or alert employees of the egress of a resident. The door had a non-working alarm. A resident was observed to exit the patio door, to the backyard, and the alarm did not sound.   3. During an interview, E1 acknowledged the patio door was not controlled and did not alert the employees of the egress of a resident from the facility.”

“Based on observation, record review, documentation review, and interview, for one of two residents reviewed, who received a controlled substance, the manager failed to ensure that policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility.   Findings include:   1. In observation, R2 had Lorazepam medication on site. The medication label indicated 60 tablets were dispensed on January 31, 2025, and twelve tablets remained in the blister pack.   2. In record review, R2's medical record (received directed care and medication administration services) included a medication order for Lorazepam 0.5 mg, one tab by mouth BID, and one tab by mouth PRN. R2's medication administration record (MAR) did not include documentation of an inventory of the controlled substance.   3. In documentation review, a facility policy, titled, "Medications," documented, "... 25) Narcotics will be controlled and stored by the facility...Daily narcotic administration will be reported on each resident MAR. As needed narcotic administration will be recorded in the resident MAR and weekly count number of pills record will be kept separate for each resident to ensure proper inventory..." The policy did not indicate how all controlled substances would be inventoried.    4. During an interview, E1 reported that R2 received the Lorazepam medication as ordered; however, acknowledged that the facility did not maintain an inventory of controlled substances, in accordance with the facility's policy and procedures.”

“Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's record revealed a current written service plan for directed care services dated July 26, 2023. This service plan stated "check pressure areas and feet daily". However, documentation was not available indicating this service was provided September 1 - present. 2. In an interview, E1 acknowledged R1's medical record did not include documentation of the above listed service and reported the service was provided as indicated in the service plan.”

“Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility, for one of two residents reviewed. The deficient practice posed a health and safety risk if the resident needed to exit the facility in an emergency. Findings include: 1. Review of R2's medical record revealed no documentation of orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility. Based on R2's date of acceptance, this documentation was required. 2. In an interview, E1 acknowledged documentation was not available showing R2 was oriented to the current facility's evacuation plan.”