Hacienda De Luna Assisted Living LLC

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the water temperature measured at 131.6\'b0 F in a resident's private bathroom. 2. In an interview, E1 and E2 acknowledged the hot water temperatures had not been maintained between 95 \'b0F and 120 \'b0F in an area of the assisted living facility used by residents.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan, dated July 26, 2024, for personal care services including medication administration. 2. A review of R2's medical record revealed a list of medication orders, dated July 24, 2024, which included the following: - "Losartan Potassium, 1 Tablet Oral 1 times a day for hypertension (100 MG tablet), Give one tablet by mouth daily for high blood pressure. Hold if SBP is less than 100." 3. A review of R2's medical record revealed an electronic Medication Administration Record (eMAR) dated November 2024. The eMAR documented the following: - "Losartan 100 MG, take 1 tablet by mouth once daily for hypertension," had been administered to R2 on each day between November 1, 2024 and November 5, 2024. However, documentation of R2's systolic blood pressure prior to each administered dose was not available for review. 4. In an interview, E1 and E2 acknowledged R2's Losartan had not been administered in compliance with the available medication order.

Based on documentation review, observation, and interview, the manager failed to ensure, for means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, the means of exiting controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. A documentation review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed a sliding glass door in the living room. The door did not control egress and was equipped with a door alarm to alert employees of the egress of a resident from the facility. However, the magnet was missing and the door alarm did not sound when the door was opened. 3. In an interview, E1 and E2 acknowledged there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort which did not control or alert employees of the egress of the resident. E1 immediately installed a new door alarm and verified it was functioning.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer, accurate to plus or minus 3\'b0 F, which posed a health and safety risk if the refrigerator was not maintained at a proper temperature. Findings include: 1. During the facility tour with E1 and E2, the Compliance Officer observed a refrigerator in the kitchen of the facility. The refrigerator contained a thermometer, however, the ethanol tube was detached from the scale and the thermometer could not be read. 2. During the facility tour with E1 and E2, the Compliance Officer observed a refrigerator in a storage room adjacent to the kitchen. The refrigerator contained a thermometer, however, the thermometer read 70 degrees Farenheit and appeared to be non-functional. 3. In an interview, E1 and E2 acknowledged the refrigerators in the facility did not have accurate thermometers. E2 replaced both thermometers during the on-site inspection, and both refrigerators were re-checked at 40 degrees Farenheit.