Loving Heart Alh

Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. Findings include: 1. A review of facility documentation revealed an incident report, dated June 16, 2025, which documented an argument between E3 and O1. The incident report did not reveal the nature of the argument, but indicated O1 refused to return to the facility. 2. In an interview, E1 advised E1 had spoken with E3 and learned the argument was regarding O1 not providing laundry services for R1. 3. In an interview, R3 reported E3 had handled R3 “rough,” repeatedly. R3 did not make any statement to indicate E3 verbally abused R3 or spoke in a disrespectful way towards R3. R3 indicated they had informed E1 of E3’s rough treatment and asked E1 to make E3 stop. R3 did not know if E1 ever addressed R3’s concerns with E3, but advised E3 continued to handle R3 roughly. 4. In an interview, E2 advised E2 had heard residents complain about E3 speaking rudely to residents, yelling at residents, and handling them roughly. E2 reported E2 had spoken to both E3 and E1 about E3’s treatment of the residents. E2 stated E1 indicated they would speak with E3 about E3's treatment of residents. E2 advised E2 had spoken to E1 numerous times, over several years, about E3’s treatment of residents, but E3’s behavior never changed. 5. In an interview, O1 advised they were visiting R1 in the middle of June 2025, when R1 complained E3 had “pinched” R1 and was “jabbing” E3's knuckles into R1’s side to get R1 to move. O1 said R1 reported E1 spoke to R1 in a condescending and demeaning way. O1 reported R1 advised E3 had told R1 to “shut up” on more than one occasion. O1 stated they had reported their concerns about E3’s treatment of R1 to E1. 6. A review of facility documentation revealed a 3-ring binder used to document the visitation of residents by persons outside the facility. Records reflect O1 visited R1 numerous times in June 2025, with the last documented visit occurring on June 16, 2025. 7. In an interview, E1 denied any prior knowledge of E3’s treatment of R1 or any of the other residents. E1 acknowledged if E3 had pinched or pressed their knuckles into residents’ sides, or if E3 had spoken rudely to residents and told them to shut up, then E3 would have been treating residents without dignity or respect.

Based on document review, record review, and interview, for one of two residents sampled, the manager failed to obtain a documented residency agreement, which included the signature of the resident. Findings include: 1. A review of facility documentation revealed the facility underwent a change of ownership, and a new license was issued on January 9, 2025. 2. A review of R1’s medical record revealed R1 was originally accepted into the facility in 2017. Further review revealed a residency agreement, signed by R1 in 2017. However, evidence of a residency agreement between the new facility and R1 was unavailable for review. 3. In an interview, E1 advised the residency agreement signed in 2017 was between R1 and the previous facility owner. E1 acknowledged a new residency agreement between the facility and R1 had not been had not been created when the facility changed ownership on January 9, 2025.

Based on record review and interview the manager failed to ensure, for one of two residents sampled, a resident had a written service plan which included the level of care the resident is expected to receive. Findings include: 1. A review of R2’s medical records revealed a service plan which indicated R2 was to receive “Supervisory” level of care. Further review revealed R2 was to receive numerous assisted living services, such as medication administration, as well as bathing, dressing, grooming, and oral care, all of which required “Maximum Assistance.” The service plan also included a section titled “General Appearance,” which indicated “Resident has reduced physical function” and “Resident requires total assistance and is confined to bed or wheelchair.” 2. In an interview, E1 advised R2 was non-ambulatory and required assisted living services beyond the supervisory level of care. E1 agreed R2’s service plan did not accurately reflect the level of care R2 required.

Based on record review and interview, the manager accepted and retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2), for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R2's service plan (dated April 10, 2025) revealed R2 received supervisory care services and was confined to a bed or chair. 3. A review of R2's medical record revealed evidence of documentation indicating R2’s medical provider or other medical practitioner examined R2, reviewed the assisted living facility's scope of services, and signed a determination stating R2’s needs could be met by the facility, was unavailable for review. 4. In an interview, E1 acknowledged R2's medical record did not include the required determination per R9-10-814(B)(2).

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 Officer observed a double-door cabinet next to the kitchen. A note was attached to the right side cabinet door, which read “Keep this door locked at all times…Per Management's Request.” The cabinet doors were affixed with two overlapping hasps which fit over a metal loop, and could be secured with a single lock. The lock was inserted through the loop; however, the lock was not secured. A resident was observed sitting at the dining room table, approximately 5 feet from the cabinet. The only employee in the facility was a caregiver, who had left the area unattended and gone to an area in the back of the facility, out of sight. The Compliance Officer opened the cabinet doors and observed numerous prescription and over-the-counter medications in plastic bottles, blister packs, and medication organizers. 2. In an interview, E1 agreed the medications stored at the facility were not in a locked room, closet, cabinet, or self-contained unit as required.