Devoted Hearts Senior Care Home Llc

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above when LPA and Licensee observed R4’s medication pill planner filled with medication tablet unlock on the kitchen counter next to the stove, which poses an immediate health, safety or personal rights risk to person in care.

Give PRN medication by physician order

Based on interviews, observation, and records review, R2’s morning medications were not administered on 10/24/25 and R1’s medication Cinacalcet 30mg and Benazepril 40 mg as directed by physician, which poses an immediate health and safety risks to persons in care.

Document each PRN medication dose taken

Based on interviews and records reviewed, R1’s medication Multi-50 plus for Her vitamin was not record in the resident’s MAR. 4 out of 5 residents medications were administered on 10/24/25 in the morning and not recorded, which poses a potential health and safety risk for the person in care.

Record centrally stored prescriptions and refill data

Based on observation and record review, licensee did not comply with the section cited above when R3’s medication Citalopram HBR 20 mg was administered daily and not recorded in R3’s Centrally Stored Medication List (Lic 622), which poses a potential health, safety or personal rights risk to persons in care.

87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.This requirement is not met as evidenced by: Based on observation and records reviewed, R1 is receiving hospice care using hospital bed with full rail with doctor’s order for half rail, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Food quality controls and rejected damaged goods

87555(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state, and local authorities. Good in damaged containers shall not be accepted, used, or retained.This requirement is not met as evidenced by: Based on observation, expired nonperishable food was observed, poses/posed an immediate health, safety or personal rights risk to persons in care.

Give PRN medication by physician order

87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.This requirement was not met as evidenced by: Based on interviews, observation, and records review, R1 and R2’s morning medications were not administered on 09/09/25 as directed by physician, which poses an immediate health and safety risks to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above when LPA observed cleaning supplies unlock under kitchen counter, staff closet, and in garage unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Give PRN medication by physician order

Based on records review and observation, staff did not administer 3 out of 4 medications for R1 as directed byphysician and staff administered expired medication to R2, which poses an immediate health and safety risk for the person in care.

Record centrally stored prescriptions and refill data

Based on observation and record review, licensee did not comply with the section cited above when R2’s Aller-zyrs Cetrizine 10 mg was not logged in centrally stored list which poses a potential health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above when LPA and Licensee observed medications unlock in room 1, room 2, and in the garage mini refrigerator, which poses an immediate health, safety or personal rights risk to person in care.

Dispose of unused medications with required witness

Based on observation, destructed medications for residents for former residents and current residents were observed stored under kitchen counter no processed to be disposed and destroyed, which poses a potential health, safety or personal rights risk to person in care

Based on records review, S1 and S2 did not have a TB result on file which poses a potential risk to the health and safety of the residents.