A PARADISE FOR PARENT'S SENIOR LIVING LLC

Based on observation, interview, documentation review, and record review, the manager failed to ensure a personnel record was established and maintained for each employee as required. The deficient practice posed a risk as required information could not be verified for E1 and E2.

Findings include:

1. When the Compliance Officers arrived at the facility, E1 and E2 were observed at the facility.

2. In an interview, E1 and E2 were hired as caregivers identifying May 2, 2024, as their first day of work at AL10123.

3. A review of the facility's policies and procedures signed February 15, 2024, revealed a policy titled "Qualifications Caregivers, Assistant Caregiver and Volunteers." The policy stated "5) A manager shall ensure that a personnel record for a personnel member, employee, volunteer, or student include: full name, date of birth, current address and phone number, date of hire, work experience and references..." An additional policy titled "Orientation and in-service training" stated "New employee orientation is required to be completed by all new employees before starting to provide assisted living services to the residents..."

4. A review of E1's personnel file revealed no documentation of E1's date of employment, contact telephone number, verification of skills and knowledge, orientation, work experience and references.

5. A review of E2's personnel file revealed no documentation of E2's date of employment, contact telephone number, verification of skills and knowledge, orientation, work experience and references.

6. In an interview, E7 reviewed E1 and E2's personnel record. E1 acknowledged the identified documents were missing from E1 and E2's personnel record for AL10123.

7. In an interview, E2 reported E4 provided E2 orientation to the facility the previous day. However no documentation of the orientation was available for review.

8. In a phone interview, E3 acknowledged personnel records were not fully established for E1 and E2.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for one of two residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements.

Findings include:

1. Review of R1's medical record revealed a current written service plan for personal care services dated April 25, 2024. However, the service plan did not include a signature and date from the resident or representative.

2. In an interview, E7 acknowledged R1's service plan did not include a signature and date from the resident or representative.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for two of two residents reviewed.

Findings include:

1. A review of facility documentation revealed R2's Medication Administration Record (MAR) dated May 2024. The MAR revealed no documentation R1 received medication administration on May 1, 2024. A review of R1's medication record revealed medication orders for the following medications; Metoprolol 25 mg take one tab PO BID, and Lisinopril 20 mg take one tab PO QD.

2. A review of R1's medications revealed the identified medications were available.

3. In an interview, E4 reported E4 administered the medications to R1 on May 1, 2024. E4 acknowledged E4 did not document the administration of the medication in R1's medical record for the date identified.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill 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 the disaster plan.

Findings include:

1. Review of the May 2024 personnel schedule revealed two shifts; 7am-730 pm and 7pm-730 am.

2. Review of the facility's employee disaster drills revealed the following drills;

March 1, 2024, at 9:10 am
March 2, 2024, at 6:03 pm
March 4, 2024, at 3:15 pm

December 1, 2023, at 8:45 am
December 5, 2023, at 5 pm
December 2, 2023, at 8 pm

September 1, 2023, at 9:15 am
September 2, 2023, at 4:30 pm
September 4, 2023, at 7 pm

June 1, 2023, at 9:15 am
June 5, 2023, at 6:30 pm

3. In an interview, E7 acknowledged the employee disaster drills were not conducted on each shift at least once every three months.