Seven Haven II LLC

Based on record review and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of two caregivers reviewed. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. Review of E2's personnel record revealed E2 worked as a caregiver. The personnel record revealed a first aid and CPR card with an expiration date of March 18, 2024. There was no other current documentation of first aid and CPR training in E2's record. 2. In an interview, E1 acknowledged E2's first aid and CPR training had expired.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of one resident reviewed who was confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed a document titled "Resident Form 02" dated and signed by a medical practitioner June 18, 2022. The document reported that R1 was chair bound and stated "I authorize this individual to reside or continue to reside in this assisted living facility. I understand that if any of the above exists, the resident's primary care provider shall examine the resident at least once every six months throughout the duration of the resident's condition and signs and dates a statement authorizing continued residency." However, R1's medical record did not include evidence of a determination signed and dated by the resident's primary care provider or other medical practitioner at least once every six months. 2. Review of R1's medical record revealed a service plan for directed care updated March 1, 2024 which reported that R1 ambulates only "with wheelchair". 3. In an interview, E1 acknowledged R1's medical record did not include evidence of a determination signed and dated by the resident's primary care provider or other medical practitioner at least once every six months.

Based on documentation review, observation, and interview, the manager failed to ensure there was a 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, that provided access to an outside area, 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. The facility was licensed at the directed care level. 2. During an environmental inspection of the facility with E1, the Compliance Officer observed two doors leading to a backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The doors did not have a device that alerted employees of the egress of a resident from the facility and were unlocked. 3. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a health risk to the residents. Findings include: 1. The Compliance Officer observed a refrigerator in the kitchen that contained food items. However, the thermometer in the refrigerator measured the temperature of the refrigerator at 55\'b0F. 2. In an interview, E1 acknowledged that foods requiring refrigeration were not maintained at 41\'b0 F or below.