Hilda's Haven Alf #6

Based on record review and interview, the assisted living home failed to prepare a written document for emergency responders which included whether the resident receives medication services, the address of the resident's current pharmacy, basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known, a copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge, and a copy of the resident's advance directives. Findings include: A review of R1's medical record revealed an emergency responder packet. However, the packet did not include the following: Whether R1 received medication services. The packet did include a list of R1's medications The address of R1's current pharmacy. Basic information about the R1's physical and mental conditions and basic medical history A copy of the R1's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. A copy of the resident's advance directives. The packet included a "Do Not Resuscitate" form, but it was not printed on orange paper as required. In an exit interview with E1, E2, and E3, the findings were reviewed and no additional information was provided.

Based on observation, record review, documentation review, and interview, the manager failed to establish, document and implement a policy and procedure for inventorying controlled substances. Findings include: The Compliance Officers observed a tote containing R2's medications contained a bottle of Lorazepam tablets. A review of R2's medical record revealed a form titled "Narcotic Medication Flow Sheet," dated March 2026. The form documented an initial quantity of 60 pills and indicated the medication had not been administered in March 2026. The form did not include a count of the medications. A review of R2's medical record revealed a form titled "PRN Medication Flow Sheet," dated March 2026, for "Lorazepam 0.5 mg." This form included columns to mark the date, time, count, and signature. However, the form was blank. In an interview, E2 reported because no lorazepam had been administered, the medication had never been inventoried. A review of the facility's policies and procedures, reviewed and updated on July 10, 2025, revealed a medication policy which included a policy titled "Part V - Storing, inventory and disposing controlled substances." However, this policy did not include a policy to inventory scheduled controlled substances at all, and did not provide a frequency for the inventory of "as-needed" controlled substances or who was responsible for the inventory. The policy only stated the "as needed narcotic administration will be recorded and inventoried in the Narcotic Administration Record separate for each resident to ensure proper inventory." In an exit interview with E1, E2, and E3, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic material stored by the assisted living facility were maintained in a locked area inaccessible to residents. Findings include: During an environmental tour of the facility, the Compliance Officers observed an office area located in the kitchen. A cabinet above the office desk did not have a lock and was accessible to residents. Inside the cabinet, the Compliance Officers observed a clear plastic tote containing nail care supplies, including a bottle of acetone. In an exit interview with E1, E2, and E3, the findings were reviewed and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, the 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, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away 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 documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed a door leading from R3's and R4's shared bedroom to the back yard. The outside area in the back yard allowed residents to be at least 30 feet away from the facility. However, the door did not have a device to alert employees of the egress of a resident from the facility. 3. The Compliance Officer observed three ambulatory residents on the premises. 4. In an interview, E1 acknowledged the manager failed to ensure the 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, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility.

Based on observation and interview, the manager failed to ensure a resident bathroom contained a slip-resistant surface in the shower. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a bathroom with a shower in the shared bedroom of R3 and R4. However, the shower did not contain a slip-resistant surface. 2. During the environmental inspection of the facility, the Compliance Officer observed a bathroom with a shower in the hallway closest to the kitchen and bedroom 3. However, the shower did not contain a slip-resistant surface. 3. In an interview, E1 acknowledged the showers in the aforementioned bathrooms did not contain a slip-resistant surface.