DEVOTED HEARTS ASSISTED LIVING LLC

INSP-0115673

Complete

Date: 4/8/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-05-05

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on April 8, 2025:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

R9-10-113.B.1-2. Tuberculosis Screening B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC), ii. Was administered within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution, and iii. Includes the date and the type of tuberculosis screening test; b. If the individual had a history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, compliance with subsection (A)(2)(b); or c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R9-6-101; and ii. Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution; and 2. As part of the annual assessment of the health care institution's risk of exposure to infectious tuberculosis according to subsection (A)(2)(d), ensure that documentation is obtained for each individual required to be screened for infectious tuberculosis that: a. Indicates the individual's freedom from symptoms of infectious tuberculosis; and b. Is signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101.

Evidence/Findings:

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) were provided annually to individuals employed by the health care institution, for two of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E1's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E1's date of hire, this documentation was required. 2. A review of E2's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E2's date of hire, this documentation was required. 3. In an interview, E1 acknowledged E1's and E2's personnel records did not include documentation of initial and annual training on recognizing the signs and symptoms of TB.

Temporary Solution:

On April 10, 2025, Manager Dorina Serrano conducted training and handed out training material to caregiver/employee and to herself in compliance to Rule R9-10-113.B.1-2

Permanent Solution:

Manager Dorina Serrano will make sure that all caregivers/employees of this Residential Group Home (Devoted Hearts Assisted Living) will undergo Annual Training to be familiar in recognizing the signs and symptoms of TB and will make sure that documentations of their training will be on their employee files.

Person Responsible:

Dorina Serrano, Manager/Owner/Caregiver

Deficiency #2

Rule/Regulation Violated:

R9-10-807.A.1-2. Residency and Residency Agreements A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident's date of occupancy, and 2. As specified in R9-10-113.

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R2's (admitted 2024) medical record did not include documentation of a completed screening to assess R2's risk of prior exposure to infectious TB and if R2 had signs or symptoms of TB. Based on R2's date of admission, this documentation was required. 3. In an interview, E1 acknowledged that R2's medical record did not contain documentation of the resident's freedom from infectious tuberculosis as specified in R9-10-113.

Temporary Solution:

After the Compliance Officer left the facility of Devoted Hearts Assisted Living, Manager Dorina Serrano went over the resident's binder and found that this particular resident indeed had a proof of Negative TB Step 1 Mantoux PPD dated ............ (pls. see attached file) which is within 12 months before admission to the residential facility ............ Manager Dorina Serrano however admits that she failed to do a Baseline TB Screening for this resident upon admission. As a temporary solution, Manager Dorina Serrano contacted a medical practitioner to do an Annual TB Symptom Screening for this resident. (Files attached)

Permanent Solution:

Manager Dorina Serrano will make sure to have a documentation of Baseline TB Screening when admitting new residents in the residential facility.

Person Responsible:

Dorina Serrano, Manager/Owner/Caregiver

Deficiency #3

Rule/Regulation Violated:

R9-10-807.B.1.a-b. Residency and Residency Agreements B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and: 1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: a. Includes whether the individual requires: i. Continuous medical services, ii. Continuous or intermittent nursing services, or iii. Restraints; and b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, 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. A review of R2's medical record revealed a document titled "Doctor's Order's Initial Admission." This document contained blanks for R2's physician to indicate whether or not R2 required continuous medical services, continuous or intermittent nursing services, or restraints. However, the form did not include the required information filled out and was not signed prior to R2’s date of admission to the facility. 2. In an interview, E1 acknowledged R2's medical record did not contain the required documentation that was dated 90 days before R2 was accepted by the facility.

Permanent Solution:

For both temporary and permanent solution, a new/updated Doctor's order that is correctly filled out has been requested from the resident's Hospice Doctor (pls. see attachment).

Person Responsible:

Dorina Serrano, Manager/Owner/Caregiver

Deficiency #4

Rule/Regulation Violated:

R9-10-815.C.6.a-b. Directed Care Services C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 6. Documentation: a. Of the resident's weight, or b. From a medical practitioner stating that weighing the resident is contraindicated; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services included documentation of the resident's weight or a medical practitioner stating that weighing the resident was contraindicated, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated March 1, 2025, that indicated R1 required directed care services. However, the service plan did not include documentation of R1's weight or documentation from R1's medical practitioner stating that weighing R1 was contraindicated. 2. In an interview, E1 acknowledged R1's service plan did not include documentation of R1's weight or documentation from R1's medical practitioner stating that weighing R1 was contraindicated. Technical assistance was provided regarding this rule during the compliance inspection conducted on August 4, 2023.

Temporary Solution:

Resident was weighed on 3/14/25 as ordered by Hospice but manager Dorina Serrano forgot to update Service Plan dated 3/1/25. During inspection on 4/8/25, manager Dorina Serrano updated the Service Plan with resident's current weight.

Permanent Solution:

Manager Dorina Serrano will make sure that weight is documented in Service Plan for residents receiving Directed Care Services, otherwise will obtain from resident's Medical Practitioner a documentation stating that weighing the resident is contraindicated.

Person Responsible:

Dorina Serrano, Manager/Owner/Caregiver

Deficiency #5

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

Based on record review, observation, and interview, the manager failed to ensure there was a means of exiting the facility that 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 R1's medical record revealed R1 received directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed the front door, back sliding door, and garage door were equipped with an alarm to alert employees of egress; however, the alarms were not turned on at the time of the inspection. 3. The Compliance Officer observed R3's bedroom to include a door that opened to the backyard. However, the door was not equipped with a means of controlling or alerting employees to the egress of R3. 4. In an interview, E acknowledged that the facility provided directed care services and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Temporary Solution:

On 4/8/25 right after the Compliance officer left the facility, Manager Dorina Serrano made sure that alarms at the exit doors were turned on, batteries replaced at the one that didn't work at the time of inspection, and alarm equipment was installed at the one exit door that didn't have at that time.

Permanent Solution:

Manager Dorina Serrano will make sure that all exit doors of the facility where an alarm that will alert employees in case of a resident's egress is required, will be permanently equipped with door alarms. These alarms will always be turned on (24/7) and for the ones that are not used daily will be checked from time to time to make sure they are working properly or if battery needs replacement.

Person Responsible:

Dorina Serrano, Manager/Owner/Caregiver

Deficiency #6

Rule/Regulation Violated:

R9-10-816.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2’s medical record revealed a medication order dated August 9, 2024, for Atenolol 25 milligrams (mg), 1 tablet by mouth (po) daily (qd) hold for systolic blood pressure (SBP) < 120 or heart rate (HR) < 66. 2. A review of R2’s medication administration record (MAR) for April 2025 revealed R2 was administered Atenolol 25 mg, 1 tablet po at 6:00 PM April 1, 2025 - present. However, R2’s MAR did not include documentation of R2’s vitals prior to administration of the medication. 3. In an interview, E1 reported R2’s vitals were not taken before the administration of Atenolol 25 mg. E2 acknowledged that medication administered to R2 was not administered in compliance with a medication order.

Permanent Solution:

On April 8, 2025 at 6:00 PM, Manager Dorina Serrano started checking and documenting patient's blood pressure before administering the medication atenolol to comply with Doctor's Order.

Person Responsible:

Dorina Serrano, Manager/Ownner/Caregiver

Deficiency #7

Rule/Regulation Violated:

R9-10-819.A.1.b. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk to residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the following materials stored on the facility's unsecured backyard table:<ul><li>A tabletop grill;</li><li>Empty planters;</li><li>Two brooms;</li><li>A soil-filled pot; and</li><li>Gardening supplies.</li></ul> 2. The Compliance Officer also observed the following materials stacked next to the facility's covered patio area:<ul><li>Roofing tiles;</li><li>A broken patio chair;</li><li>Empty planters; and</li><li>Discarded chlorine tablet containers.</li></ul> 3. The Compliance Officer observed four portable commodes lined against the facility's side wall. However, the commodes were not functional and were used to hold other discarded materials. 4. The Compliance Officer observed the facility's hose to be laid across the walkway in the facility's backyard area. 5. The Compliance Officer observed the following materials stored next to and leaning against the facility's shed:<ul><li>Broken and piled paving blocks;</li><li>Discarded poles and posts;</li><li>A discarded toilet;</li><li>Siding materials;</li><li>An empty bucket;</li><li>A broken hose;</li><li>A discarded bed frame; and</li><li>A hook attached to a wooden pole.</li></ul> 6. In an interview, E1 acknowledged that the premises and equipment used at the facility were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Permanent Solution:

For both Temporary and Permanent Solution, On 4/12/25, Manager Dorina Serrano cleared the facility premises of clutters and equipments that are no longer of use. (Pls. see attached pictures)

Person Responsible:

Dorina Serrano, Manager/Owner/Caregiver

INSP-0094888

Complete

Date: 8/4/2023

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2023-08-09

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on August 4, 2023:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

C. A manager shall ensure that policies and procedures are:
3. Reviewed at least once every three years and updated as needed.

Evidence/Findings:

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 dated November 21, 2017. However, documentation to indicate 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 at least once every three years.

Deficiency #2

Rule/Regulation Violated:

C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
c. Documentation of:
i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for for one of two caregivers sampled and for one of one assistant caregiver sampled. The deficient practice posed a risk if the employees were unable to meet a residents needs.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "APPLICANT AND EMPLOYEE REQUIREMENT" (dated November 21, 2017). The policy stated "Upon being hired by the facility the applicant must...Verification of qualifications, knowledge, and skills to perform the duties of the job hired for..."

2. A review of E3's (hired in 2016) personnel record revealed E3 was hired as a caregiver. However, documentation of the verification of E3's skills and knowledge was not available for review.

3. A review of E4's (hired in 2022) personnel record revealed E4 was hired as an assistant caregiver. However, documentation of the verification of E4's skills and knowledge was not available for review.

4. In an interview, E1 acknowledged E3's and E4's skills and knowledge were not verified and documented in the personnel records before providing physical health services and according to the facility's policies and procedures.

Deficiency #3

Rule/Regulation Violated:

C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
c. Documentation of:
iii. The individual's completed orientation and in-service education required by policies and procedures;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, for one of two caregivers sampled and for one of one assistant caregiver sampled. The deficient practice posed a risk to the health and safety of residents if caregivers were not orientated to the specific duties to be performed.

Findings include:

R9-10-101.155."Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution.

1. A review of the facility's policies and procedures revealed a policy titled "EMPLOYEE ORIENTATION AND ONGOING TRAINING POLICY AND PROCEDURE" (dated November 21, 2017). The policy stated "...The manager/owner of the facility shall ensure that a new employee completes orientation before the starting date of employment..."

2. A review of E3's (hired in 2016) personnel record revealed a document titled "Orientation Checklist" (dated in Februaury 2023). However, the following areas to indicate the orientation was completed were left blank:
-"Manager's Initals...Date"; and
-"Manager's Signature...Date."

3. A review of E4's (hired in 2022) personnel record revealed documentation E4 received orientation specific to the duties to be performed was not available for review.

4. In an interview, E1 acknowledged E3's and E4's completed orientation was not available for review.

DEVOTED HEARTS ASSISTED LIVING LLC

Facility Information

Inspection History

INSP-0115673

Summary:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0094888

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings: