Paloma Place, LLC

2 out of 3 child's files received were not signed.

In reviewing employees files, one employee did not have a current drug test completed before having contact with youth in care.

Two of Five medication blister packs were found to be inacurate according to the medication log.

Two Serious Incident Reports depicting two different incidents on different dates, have the same wording verbatim. The reports were documented by different staff

A contracted employee who provided therapy to youth in care, did not have a Tuberculosis Test

A child in care was restrained in order to comply with directives, to surrender a prohibited item (cell phone), and enter the operation.

Operation staff did not conduct an approved type of restraint on a child in care, when using a bear hug hold and walking restraint.

Serious incident report did not give an accurate account of what occurred regarding a restraint. Statements made by staff do not align with documentation in the report.

A child in care was not displaying behaviors that required emergency intervention at the time of implementing the intervention or during continued interventions.

An untrained caregiver used a restraint hold where a child's arm was placed behind their back while held against a wall.

The Incident Report did not list all witnesses present during a restraint.

A caregiver not trained in EBI was included in the implementation of a restraint of a child in care.

Staff member left children under his care/ratio without direct supervision to assist with a restraint.

There was no documentation found in the child's file stating the child's parent was notified of an EBI.

The Incident Report did not include information on who observed the child after the restraint and after PRN medication was provided.

A child in care sustained a self-inflicted laceration to the head and injury to the hand. Emergency medical treatment was obtained for the child on 8/24/2022. The incident was not reported to Licensing as required.

The initial Service Plan did not indicate who reviewed the plan with the youth in care and only the child's signature was obtained. It is important all team members provide signatures as required no later than the 15 days after the set date of the meeting to comply with minimum standards.

During a walk-through of the operation the kitchen area was observed. In the refrigerator there was a package of Hash browns that was opened, it was not properly covered.

During a walk-through of the operation a bed being used by one of the clients was found to be missing a mattress protector.

There is information to support staff use profane language around and towards children in care.

In 1 of 4 child records, it was found that a Medication Administration Record did not have the time the medication was administered for 5 of 31 days in May 2022.

In reviewing menus going back 90 days, food substitutions were not documented on the menus.

During a monitoring inspection a child in care was observed using a land line phone in the presence of two other children and one staff. The phone was located in a day room area were other children were watching TV. This did not allow for the child to have privacy.

The Administrator allowed a governing body member with restricted access to child file to be included in email communications regarding a child behaviors and information included in a child's record.

During the monitoring inspection 2 of 4 Serious Incident Reports were found to be missing full names for the staff.

13 year old child in care was slapped by a caregiver and a 14 year old child was grabbed by the throat and slammed to the floor by the same caregiver.

Permit holder told a child in care to not participate in interviews with investigators. The child did not participate in two interview attempts.

During a walk through of the operation. It was noticed that that several 2X2 railings were missing from a wooden stairway leading to the recreational area.

During a walk through of the operation, two first aid kits were found to be missing items. one kit was missing a thermometer and the other a pair of scissors. NOTE: No Action plan is required, the Deficiency was corrected at inspection.

During a walk through of the operation it was observed that an emergency evacuation and relocation diagram was not posted in a prominent and visible location.

During a review of records it was found that a caregiver was missing CPR Certification and First Aid Certification documentation in the personnel file. A second caregiver was missing First Aid Certification documentation in their personnel file.

During a review of personnel records a caregivers affidavit for employment was incomplete.