Devoted Hearts Assisted Living LLC

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) were provided annually to individuals employed by the health care institution, for two of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E1's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E1's date of hire, this documentation was required. 2. A review of E2's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E2's date of hire, this documentation was required. 3. In an interview, E1 acknowledged E1's and E2's personnel records did not include documentation of initial and annual training on recognizing the signs and symptoms of TB.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R2's (admitted 2024) medical record did not include documentation of a completed screening to assess R2's risk of prior exposure to infectious TB and if R2 had signs or symptoms of TB. Based on R2's date of admission, this documentation was required. 3. In an interview, E1 acknowledged that R2's medical record did not contain documentation of the resident's freedom from infectious tuberculosis as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R2's medical record revealed a document titled "Doctor's Order's Initial Admission." This document contained blanks for R2's physician to indicate whether or not R2 required continuous medical services, continuous or intermittent nursing services, or restraints. However, the form did not include the required information filled out and was not signed prior to R2’s date of admission to the facility. 2. In an interview, E1 acknowledged R2's medical record did not contain the required documentation that was dated 90 days before R2 was accepted by the facility.

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 a medical practitioner stating that weighing the resident was contraindicated, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated March 1, 2025, that indicated R1 required directed care services. However, the service plan did not include documentation of R1's weight or documentation from R1's medical practitioner stating that weighing R1 was contraindicated. 2. In an interview, E1 acknowledged R1's service plan did not include documentation of R1's weight or documentation from R1's medical practitioner stating that weighing R1 was contraindicated. Technical assistance was provided regarding this rule during the compliance inspection conducted on August 4, 2023.

Based on record review, observation, and interview, the manager failed to ensure there was a means of exiting the facility that 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 R1's medical record revealed R1 received directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed the front door, back sliding door, and garage door were equipped with an alarm to alert employees of egress; however, the alarms were not turned on at the time of the inspection. 3. The Compliance Officer observed R3's bedroom to include a door that opened to the backyard. However, the door was not equipped with a means of controlling or alerting employees to the egress of R3. 4. In an interview, E acknowledged that the facility provided directed care services and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for one of two 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 R2’s medical record revealed a medication order dated August 9, 2024, for Atenolol 25 milligrams (mg), 1 tablet by mouth (po) daily (qd) hold for systolic blood pressure (SBP) < 120 or heart rate (HR) < 66. 2. A review of R2’s medication administration record (MAR) for April 2025 revealed R2 was administered Atenolol 25 mg, 1 tablet po at 6:00 PM April 1, 2025 - present. However, R2’s MAR did not include documentation of R2’s vitals prior to administration of the medication. 3. In an interview, E1 reported R2’s vitals were not taken before the administration of Atenolol 25 mg. E2 acknowledged that medication administered to R2 was not administered in compliance with a medication order.

Based on observation and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk to residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the following materials stored on the facility's unsecured backyard table: A tabletop grill; Empty planters; Two brooms; A soil-filled pot; and Gardening supplies. 2. The Compliance Officer also observed the following materials stacked next to the facility's covered patio area: Roofing tiles; A broken patio chair; Empty planters; and Discarded chlorine tablet containers. 3. The Compliance Officer observed four portable commodes lined against the facility's side wall. However, the commodes were not functional and were used to hold other discarded materials. 4. The Compliance Officer observed the facility's hose to be laid across the walkway in the facility's backyard area. 5. The Compliance Officer observed the following materials stored next to and leaning against the facility's shed: Broken and piled paving blocks; Discarded poles and posts; A discarded toilet; Siding materials; An empty bucket; A broken hose; A discarded bed frame; and A hook attached to a wooden pole. 6. In an interview, E1 acknowledged that the premises and equipment used at the facility were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed and updated at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure manual dated November 21, 2017. However, documentation to indicate the facility's policies and procedures were reviewed and updated at least once every three years was not available for review. 2. In an interview, E1 acknowledged the facility's policies and procedures had not been reviewed at least once every three years.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for for one of two caregivers sampled and for one of one assistant caregiver sampled. The deficient practice posed a risk if the employees were unable to meet a residents needs. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "APPLICANT AND EMPLOYEE REQUIREMENT" (dated November 21, 2017). The policy stated "Upon being hired by the facility the applicant must...Verification of qualifications, knowledge, and skills to perform the duties of the job hired for..." 2. A review of E3's (hired in 2016) personnel record revealed E3 was hired as a caregiver. However, documentation of the verification of E3's skills and knowledge was not available for review. 3. A review of E4's (hired in 2022) personnel record revealed E4 was hired as an assistant caregiver. However, documentation of the verification of E4's skills and knowledge was not available for review. 4. In an interview, E1 acknowledged E3's and E4's skills and knowledge were not verified and documented in the personnel records before providing physical health services and according to the facility's policies and procedures.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, for one of two caregivers sampled and for one of one assistant caregiver sampled. The deficient practice posed a risk to the health and safety of residents if caregivers were not orientated to the specific duties to be performed. Findings include: R9-10-101.155."Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of the facility's policies and procedures revealed a policy titled "EMPLOYEE ORIENTATION AND ONGOING TRAINING POLICY AND PROCEDURE" (dated November 21, 2017). The policy stated "...The manager/owner of the facility shall ensure that a new employee completes orientation before the starting date of employment..." 2. A review of E3's (hired in 2016) personnel record revealed a document titled "Orientation Checklist" (dated in Februaury 2023). However, the following areas to indicate the orientation was completed were left blank: -"Manager's Initals...Date"; and -"Manager's Signature...Date." 3. A review of E4's (hired in 2022) personnel record revealed documentation E4 received orientation specific to the duties to be performed was not available for review. 4. In an interview, E1 acknowledged E3's and E4's completed orientation was not available for review.