Loving Heart Assisted Living Service

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility are free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed broken glass on the ground in the backyard. The Compliance Officers also observed a gate leading from the backyard to the front yard with a broken wood panel. This was provided as technical assistance on the inspection conducted on October 10, 2023. 2 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility’s premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed a manager's license hanging on the wall for E1. 2 . A review of facility documentation revealed a document titled "Delegation of Authority." However, the delegation of authority stated O1 was the current manager and it was signed by E1. 3 . In an exit interview, the findings were reviewed with E2, and no additional information was added.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included cardiopulmonary resuscitation training (CPR), if required for the individual in this Article or policies and procedures, for one of three personnel sampled. Findings include: 1 . A review of E3's personnel record revealed a CPR card. However, the CPR card expired March 2025. An updated card was not available for review at the time of inspection. 2 . In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation and interview, the manager failed to ensure a list of resident rights was conspicuously posted. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed a corkboard with various postings, including the manager's license and the facility license. However, a posting of a list of resident rights was not available for review at the time of inspection. 2 . In an exit interview, the findings were reviewed with E2, and no additional information was added.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed and updated at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure manual last reviewed on November 30, 2019. However, documentation to demonstrate the facility's policies and procedures were reviewed and updated at least once every three years was not available for review. 2. In an interview, E1 acknowledged the facility's policies and procedures had not been reviewed and updated at least once every three years.

Based on observation and interview, the manager failed to ensure potentially hazardous foods requiring refrigeration were maintained at 41\'b0F or below. The deficient practice posed a potential food-borne illness risk. Findings include: 1. The Compliance Officer observed a refrigerator in the kitchen contained food items. The thermometer inside the refrigerator door measured the temperature of the refrigerator at approximately 51\'b0F. The Compliance Officer measured the temperature at 56\'b0F, using a Department issued thermometer. 2. In an interview, E1 acknowledged the refrigerator's temperature was not maintained at 41\'b0F or below.