Helping Hearts Assisted Living LLC

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and 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 Department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed two ambulatory residents. 3. During the environmental tour, the Compliance Officer observed a back door leading to the backyard. However, the door was not secured and the door chime was not functioning. 4. A review of facility policies and procedures revealed a policy titled "Safety of Wandering Residents," the policy stated "5. If alarms are being used on doors and or windows, the caregiver will check them daily for operation and security. Alarms that are trigged will be investigated immediately by the caregiver on duty." 5. In an interview, E1 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. A review of the July 2024 personnel schedule revealed three shifts; 6 AM - 2:30 PM, 2 PM - 10:30 PM and 10 PM - 6:30 AM. 2. A review of the facility's employee disaster drills revealed the following drills; - December 30, 2023, at 11:10 AM - March 29, 2024, at 9:45 AM - March 29, 2024, at 6:00 PM - March 29, 2024, at 10:00 AM - June 28, 2024, at 11:50 AM 3. In an interview, E2 acknowledged the employee disaster drills were not conducted on each shift at least once every three months.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed a current written service plan, which indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders for the following medications; - Buspirone HCL 10mg 1 tab PO TID - Quetiapine 50mg 1 tab PO QHS - Donepezil HCL 5mg 1 tab PO QHS 3. Review of R1's medical record revealed a July 2024 medication administration record (MAR). This MAR stated the following: - "Buspirone HCL 10mg 1 tab PO TID" however, did not include documentation Buspirone HCL 10mg was administered at 2:30pm and 7pm July 30th. - "Quetiapine 50mg 1 tab PO QHS" however, did not include documentation Quetiapine 50mg was administered at 7pm July 30th. - "Donepezil HCL 5mg 1 tab PO QHS" however, did not include documentation Donepezil HCL 5mg was administered at 7pm July 30th. 4. In an interview, E1 reported the medications were administered per the medication orders and acknowledged R1's medical record did not include documentation the medications were administered. This is a repeat deficiency from the compliance inspection conducted March 09, 2023.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. The Compliance Officer arrived at the facility at 12:45 pm. 2. Review of R1's medical record revealed an activities of daily living (ADL) sheet for July 2024. The ADL sheet stated the following services were provided: "Bathing (2X/Week)" "Dressing (2X/Day)" "Grooming - Comb Hair, Wash Face, Oral Care (2X/Day)" "Grooming - Nail Care (1X/Day)" "Toileting - Incontinence Checks - Every 2 hours daytime" "Toileting - Incontinence Checks - Twice at night" "Night Checks" "Skin care PRN" However, the ADL sheet revealed no documentation the services were provided July 30th - present. 3. In an interview, E1 acknowledged R1's medical record did not include documentation of the above listed services July 30th - present, however, reported the services were provided. This is a repeat deficiency from the compliance inspection conducted March 9, 2023.