A Tender Touch Assisted Living Home II

Based on record review, documentation review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for two of three residents sampled. Findings include: 1. A review of R2's (admitted in 2021) medical record revealed a service plan, dated in November 2022. The plan revealed R2 was to receive the following service: -Complete bath 2x per week 2. A review of R2's medical record revealed a document, dated June 2023 and titled "Activities of Daily Living Flowsheet." The document revealed R2 received a complete bath on the following days: -June 2, 2023 -June 16, 2023 -June 23, 2023 3. A review of R3's (admitted in 2022) medical record revealed a service plan dated in May 2023. The plan revealed R3 was to receive the following service: -Complete bath 2x per week 4. A review of R3's medical record revealed a document, dated June 2023 and titled "Activities of Daily Living Flowsheet." The document revealed R3 received a complete bath on the following days: -June 14, 2023 -June 21, 2023 5. In an interview, E1 acknowledged R2's and R3's "Activities of Daily Living Flowsheets" did not reflect the services according to R2's and R3's service plans. E1 reported the caregivers who initialed the documents may have been confused by the abbreviations and documenting in error.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for one of three residents sampled who received personal care services. Findings include: 1. A review of R2's (admitted in 2021) medical record revealed a service plan, dated in November 2022 for personal care services. However, a reviewed and updated service plan was not available for review. 2. In an interview, E1 acknowledged R2 received personal care services and the service plan had not been reviewed and updated at least once every six months.