Heart to Heart Assisted Living LLC

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two 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 medical record revealed a current written service plan for personal care services dated November 2023. This service plan stated the following services were needed: "Oral care twice a day" "Assist with dressing twice a day" 2. Review of R2's medical record revealed a current written service plan for personal care services dated December 2023. This service plan stated the following services were needed: "Oral care twice a day" "Assist with dressing twice a day" However, the Activity of Daily Living Sheet dated February 2024 revealed the aforementioned services were only provided one time a day. 3. In an interview, E1 acknowledged R1 and R2's medical record did not include documentation of the above listed services and revealed the services were provided as indicated in the service plans.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2's medical record revealed a current written service plan dated December 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated December 2023. This medication order stated "Metoprolol 25 mg tablet take 1 PO daily hold for SBP [systolic blood pressure] <100 or heart rate is <50". 3. Review of R2's medical record revealed a February 2024 medication administration record (MAR). This MAR stated "Metoprolol 25 mg tablet take 1 PO daily". The MAR documented a blood pressure reading of 96/52 on February 17, 2024 and a blood pressure reading of 81/30 on February 18, 2024. The MAR documented that the medication was administered instead of being held per physician orders. 4. During an observation of R2's medications, Metoprolol 25mg was observed. 5. In an interview, E1 acknowledged R2's medication was not administered in compliance with the available medication order.