Compassionate Hands Assisted Living LLC.

“Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training in fall prevention and fall recovery. Findings include: 1 . A review of facility documentation revealed a training program for all staff regarding fall prevention and fall recovery was not available for review at the time of inspection. 2 . In an interview, E1 acknowledged a training program for fall prevention and fall recovery was not available for review.”

“Based on record review and interview, the manager failed to ensure medication administered to a resident is documented in the resident's medical record, for five of six residents sampled. Findings include: 1 . In an interview, E1 confirmed all residents received medication administration. 2 . A review of R1's medical record revealed a signed medication order dated April 15, 2025, for the following medications: -Divalproex 125 MG 2 Tablets every 12 hours; -Mirtazapine 7.5 MG once a day; -Sertraline 50 MG once a day; -Trazadone 100 MG once a day; -Haloperidol 0.5 MG 1 tablet in the morning and 2 tablets in the evening; -Docasate 100 MG once a day; -Ferrous Sulfate 325 MG once a day; -Meloxicam 7.5 MG once a day; and -Senna 8.6 MG once every 12 hours. However, a review of R1's Medication Administration Record (MAR) sheet revealed the above medications were not documented as administered on April 26, 2025 and April 27, 2025. 3 . A review of R2's medical record revealed a signed medication order dated December 21, 2024, for the following medications: -Pantoprazole 40 MG once a day; -Alprazolam 0.25 MG once a day; -Seroquel 50 MG once a day; -Seroquel 25 MG once a day; and -Trazadone 50 MG once a day; However, a review of R2's Medication Administration Record (MAR) sheet revealed the above medications were not documented as administered on April 26, 2025 and April 27, 2025. 4 . A review of R3's medical record revealed a signed medication order dated April 10, 2025, for the following medications: -Calcium 600 MG tablet twice a day; -Vitamin D3 5 MCG tablet twice a day; -Levothyroxine 75 MCG 2 tablets once a day; -Eliquis 5 MG 1 tablet twice a day; -Amlodipine 5 MG tablet once a day; -Atenolol 50 MG tablet twice a day; -Magnesium 400 MG tablet once a day; -Cyanocobalamin 1,000 MCG tablet once a day; -Hydralazine 25 MG tablet three times a day; -Gabapentin 400 MG tablet four times a day; -Tizanidine 4 MG tablet once every eight hours -Levetiracetam 250 MG 3 tablets two times a day; and -Modafinil 100 MG tablet once a day. However, a review of R3's Medication Administration Record (MAR) sheet revealed the above medications were not documented as administered on April 26, 2025 and April 27, 2025. 5 . A review of R4's medical record revealed a signed medication order dated April 10, 2025, for the following medications: -Trazadone 50 MG once a day; -Losartan 100 MG tablet once a day; -Loratadine 10 MG tablet once a day; -Sertraline HCL 50 MG tablet once a day; -Meloxicam 7.5 MG tablet once a day; -Amlodipine 10 MG tablet once a day; -Atorvastatin 10 MG tablet once a day; -Levothyroxine 25 MCG tablet once a day; -Memantine HCL 5 MG tablet once a day; and -Acetaminophen 500 MG tablet twice a day. However, a review of R4's Medication Administration Record (MAR) sheet revealed the above medications were not documented as administered on April 26, 2025 and April 27, 2025. 6 . A review of R5's medical record revealed a signed medication order dated April 14, 2025, for the following medications: -Senna S 8.6 MG 2 tablets twice a day; -Seroquel 25 MG once a day; -Oxybutynin 5 MG 1 tablet twice a day; and -Lorazepam 0.5 MG every 4 hours. However, a review of R5's Medication Administration Record (MAR) sheet revealed the above medications were not documented as administered on April 26, 2025 and April 27, 2025. 7 . In an interview, E1 acknowledged medication was not documented as administered on April 26, 2025 and April 27, 2025 for R1, R2, R3, R4, and R5.”

“Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food or medication contains a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer did not observe a thermometer placed inside the refrigerator at the facility. 2 . In an interview, E1 acknowledged a thermometer had not been placed inside the refrigerator.”

“Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed every 12 months. Findings include: 1 . A review of facility documentation revealed documentation of a disaster plan review conducted every 12 months was not available for review at the time of inspection. 2 . In an interview, E1 acknowledged documentation of a disaster plan review conducted every 12 months was not available for review at the time of inspection.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed an unlocked cabinet in a resident bathroom under the sink. The cabinet had magnetic locks. However, the left cabinet magnetic lock was turned off, and the right magnetic lock was not functioning correctly. The Compliance Officer was able to access the following inside the cabinet: -A can of "Scrubbing Bubbles" bathroom cleaner; -A can of "Comet" bleach; and -A bottle of "Arm & Hammer" bathroom cleaner. 2 . In an interview, E1 acknowledged poisonous or toxic materials stored by the assisted living facility were accessible to residents”

“Based on documentation review, the manager failed to ensure a pest control program is implemented and documented. Findings include: 1 . A review of facility documentation revealed documentation of an implemented pest control program was not available for review at the time of inspection. 2 . In an interview, E3 reported E3 had been spraying at the home, and did not have a certification. E1 acknowledged a pest control program was not implemented or documented.”