Helping Hands 2

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift, at least once every three months, and documented. Findings include: 1. A review of facility staffing schedules revealed the facility operated three shifts: days, 7:00 a.m. – 3:00 p.m., swing shift, 3:00 p.m. – 11:00 p.m., and nights, 11:00 p.m. – 7:00 a.m. 2. A review of facility documentation revealed evidence of documentation of an employee disaster drill conducted during the day shift on September 3, 2024 and December 9, 2024, on the swing shift on October 5, 2024, and January 5, 2025, and the night shift on August 4, 2024, and January 5 and February 5, 2025. However, evidence of documentation of any additional employee disaster drills conducted on any shift, after February 5, 2025, was unavailable for review.. 3. In an interview, E1 agreed disaster drills were not being conducted on each shift, at least once every three months, and documented.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During a tour of the facility, the Compliance Officers observed a kitchen cabinet, which was not secured. Inside the cabinet, the Compliance Officers observed a box marked “Thereflu Severe Cold Relief, Acetaminophen, Dextromethorphan HBR.” Inside the box, the Compliance Officers observed three blue and white capsules, enclosed in a blister pack. The back of the packaging read “Rosel, Amantadina, Clorfenamina, Paracetamol, Capsula 50 mg/3 mg/300 mg.” 2. In an interview, E1 advised the Rose medication was from Mexico and was used for treating flu symptoms. E1 agreed the medications stored at the facility were not in a locked room, closet, cabinet, or self-contained unit as required.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation which may cause a resident or other individual to suffer physical injury. Findings include: 1. During a tour of the facility, the Compliance Officers observed exposed electrical wiring, dangling within arm's reach, outside a resident’s bedroom. The exposed wiring was attached to a metal plate, possibly from a lighting fixture. The wiring ends were capped; however, the insulation had been stripped, and exposed copper wire was observed. 2. In an interview, E1 agreed the exposed wire presented a hazardous condition which may cause an individual harm due to electric shock.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, separate from medications and inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed no fewer than two ambulatory residents. The Compliance Officer also observed a hall closet equipped with a locking mechanism, however the locking mechanism was not engaged and the closet was opened with little effort. Inside the closet was a one gallon plastic container of "Multi-Purpose Disinfecting Cleaner," which was marked "KEEP OUT OF REACH OF CHILDREN." 2. In an interview, E1 acknowledged the poisonous and toxic materials were not kept separate from medications, in a locked area, inaccessible to residents.