Heart to Heart Assisted Living LLC.

“Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a current written service plan for personal care services dated November 2023. This service plan stated the following services were needed: "Oral care twice a day" "Assist with dressing twice a day" 2. Review of R2's medical record revealed a current written service plan for personal care services dated December 2023. This service plan stated the following services were needed: "Oral care twice a day" "Assist with dressing twice a day" However, the Activity of Daily Living Sheet dated February 2024 revealed the aforementioned services were only provided one time a day. 3. In an interview, E1 acknowledged R1 and R2's medical record did not include documentation of the above listed services and revealed the services were provided as indicated in the service plans.”

“Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2's medical record revealed a current written service plan dated December 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated December 2023. This medication order stated "Metoprolol 25 mg tablet take 1 PO daily hold for SBP [systolic blood pressure]”