Heartlight Ministries

Children in care were able to secure tools from restricted areas at the operation- which enabled them to dismantle the window in their cottage and engage in illegal activities.

During the walkthrough, I observed the following physical site issues to be in compliant: A shower head in one of the resident bathrooms was broken and needed replacing, a small closet/storage area door in one of the cottages was broken with exposed nails, the cabinet in the laundry room of one cottage has been broken with a maintenance report on file since 7/27/24, a toilet in one cottage lacked a tank lid with a maintenance report filed 9/2/24. I observed the following to still be deficient and an extension is being granted: shower surround in one bathroom evidenced a peeling backing board above the shower surround,and a broken bathroom door. I observed a new deficiency during my walk through. There wa drywall damage in Vickie's Main half bath.

During the walkthrough, we observed uncovered food in the refrigerator of one of the cottages.

During the walkthrough, I observed two freezers in one of the houses has replaced the missing thermometers.

During the walkthrough, we observed the following physical site issues: A shower head in one of the resident bathrooms was broken and needed replacing, shower surround in one bathroom evidenced a peeling backing board above the shower surround, a small closet/storage area door in one of the cottages was broken with exposed nails, the cabinet in the laundry room of one cottage has been broken with a maintenance report on file since 7/27/24, a toilet in one cottage lacked a tank lid with a maintenance report filed 9/2/24. Items with maintenance reports on file are not being completed in a timely manner.

During the inspection, we observed a bathroom in one of the lodges lacking any toilet paper.

During the walkthrough, we observed two bathrooms lacking handtowels in the restrooms.

During the DFPS investigation, it was discovered the operation failed to properly supervise children in care, resulting in the children being able to "cheek" medications as well as crushing and snorting medications brought home from the hospital.

During the DFPS investigation, it was discovered the operation failed to secure poisonous cleaning supplies, allowing children unsupervised access.

This deficiency was noted as part of a DFPS investigation.

During the investigation inspection, there was potatoes stored on the pantry floor of New Lodge and Vickie's House.

During the investigation inspection, it was observed the four showers located in the East House only had lukewarm/room temperature water for the children to shower.

During the investigation inspection, there was mold/mildew observed in the bathroom of the East House and Old Lodge. There was also sheet rock damage observed a bathroom located in the East House.

During the investigation inspection, there was a first aid kit stored, unlocked and accessible to children, in the bathroom of the East House. The first aid kid contained topical creams and cold compress both of which were labeled to keep out of reach of children.

During the investigation inspection, the thermometer located in the East House freezer indicated the freezer was at 16 degrees Fahrenheit, and not at the required 0 degree Fahrenheit or below. Additionally, the thermometer located in Vickie's House refrigerator indicated the refrigerator was at 45 degrees Fahrenheit, and not at the required 40 degree Fahrenheit or below.

This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, staff initiated restraints for in non-emergency situations.

This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a staff member restrained a child about the head or throat area during a restraint.

This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a safety plan established on 5/16/24 indicated a specific staff member would not administer restraints until the close of the ongoing investigation, but documentation indicates the staff member engaged in a restraint on 6/11/24.

During the ANE investigation, it was discovered that five of six residents interviewed reported staff cursing and yelling at them.

This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a staff member utilized restraint as a means to gain compliance from a child that refused to leave a peer's room.

This concern arose during the course of the DFPS investigation, based on a review of the evidence obtained, a staff member failed to secure a box of over-the-counter medication stored in the staff office, resulting in a resident accessing and ingesting the medication without supervision.

During the inspection, I observed three refrigerator thermometers reading in excess of the permitted 40 degrees, and one deep freeze unit lacked a thermometer.

During the walkthrough, I observed excessive dust and cobwebs and cracked paint near the ceiling in one of the bedrooms.

During the inspection, I observed a drainage issue in the sink of one cottage, a toilet holding human waste that did not cycle when tested in another cabin, and a cracked shower stall in a third cabin. None of these repairs had work orders filed on them at the time of the inspection.

During the walkthrough, I observed an open water valve recess outside a cottage lacking a protective cover, creating a tripping hazard. The operation replaced this cover at the time of the inspection.

During the inspection, I observed one child's initial medical exam was completed 24 days past the 30 days from admission date.

During the inspection, I observed two beds without protective mattress covers. The operation replaced the mattress covers during the inspection.

During the monitoring inspection, one child's medication record was reviewed and observed to be missing the full name of the person who administered the medication.

During the monitoring inspection, it was observed that two children's medication record and actual medication count did not match. The medication record reflected there were 4 doses remaining while the package only contained 2 doses and another child's medication record indicated 3 doses remaining but the package contained 4 doses.

During the inspection, I observed that one of the maintenance staff hired on 5/1/23 does not have an initial background upon hire with the facility.

During the inspection, I observed a mini fridge in one of the cabins that exhibited a thermometer reading of 50 degrees Fahrenheit. The operation turned down the temperature in the unit during the inspection to correct the temperature.

During the walkthrough, I observed that one of the fire extinguishers in a resident cabin lacked a tag or documentation denoting when it was last serviced. The operation replaced the fire extinguisher during the walkthrough with one that was properly tagged.

During the inspection, I observed a cottage cabinet with a hole broken through it that staff reported being there over two weeks. The lights in the laundry room of one cabin were burned out and were replaced by the operation during the walkthrough.

In reviewing the documentation and investigation interviews, I observed that the operation failed to report the serious accidental injury of a resident within 24 hours.

During the investigation inspection, there was a jug of mop solution located under the kitchen sink, unlocked, in the New Lodge Home.

During the inspection, I observed two refrigerators without requisite thermometers.

During the inspection, I observed four mattresses on the floor of loft areas in the cabins.

During the inspection, I observed a light switch in one cottage with a missing face plate, and a cabinet door in another cottage had a faulty hinge.

In one of six employee records reviewed, the caregiver employee did not receive 16 hours of EBI preservice training. Only two hours were documented for the employee in the file.

During the walkthrough, I observed holes in the drywall in the bedroom of one lodge and the downstairs bathroom of the second lodge.

In one of the six employee files read, the record did not reflect the employee receiving annual Normalcy training in the past two years.

The purpose of this rule is to protect the health, safety and well being of children in care by ensuring that caregivers are provided and are informed of all the child's needs, medical conditions and any other information of the children they are supervising.

A Staff Member was provoking / antagonizing the child in care by raising her voice and saying things such as ?oh your pissed off, there?s the door? and ?your mad at me so why don?t you hit me.

(2) out of (6) records reviewed were missing a dental examination. One record indicated that an appointment was rescheduled, however, there was not an appointment scheduled.

In 4 of 4 records reviewed there was not a documented notice given for the child service planning meeting.

(1) of the (2) homes inspected had emergency evacuation and relocation diagrams that did not include designated location outside of the building. Also, the designated meeting place for weather disaster was not included. This is a separate standard, but all designated meeting areas for emergency evacuation should be included on the diagram.

A child drank hand sanitizer and had to be taken to the Emergency Room. Staff failed to report this incident to the hotline.

Six out of the eight emergency behavior interventions records reviewed showed no time of the incident.

There were two unreported suicide attempts on 3/7 and 3/8/2021.

Two of the eight emergency behavior intervention records reviewed showed that caregivers failed to re-explain every 15 minutes what the child needed to do in order to be released from the intervention.

Two cabins were inspected and one bed was missing a mattress protector; and another bed was missing a pillowcase.

The operation failed to report a child in care was taken to the hospital for an allergic reaction to a known nut allergy, that warrant treatment by a medical professional.