Ambience Care Home 2

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a bottle of "Downy" fabric softener in an unlocked closet in a common area hallway. 2 . During an environmental inspection of the facility, the Compliance Officer observed a can of "Zep" foaming wall cleaner, a can of "Sprayaway" glass cleaner, and a bag of "Cascade" detergent pods accessible in a resident bathroom. 3 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

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 two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan dated in June 2023. The plan revealed R1 was to receive the following service: -2x per week bath 2. A review of facility documentation revealed a binder with activities of daily living (ADL) documents. The binder included an ADL document for August 2023 for R1 and revealed R1 received a full bath on the following day: -August 6, 2023 3. A review of R2's medical record revealed a service plan dated in August 2023. The plan revealed R2 was to receive the following service: -2x per week bath 4. A review of facility documentation revealed a binder with ADL documents. The binder included an ADL document for August 2023 for R2 and revealed R2 received a full bath on the following day: -August 6, 2023 5. In an interview, E1 acknowledged R1's and R2's ADL documents did not indicate R1 and R2 received services per their service plans. E1 was unable to provide additional information about when R1 and R2 received full baths but reported E1 felt the documentation was done in error and not documented correctly.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's needs required in R9-10-807(B), for one of two residents sampled. The deficient practice posed a risk if the residents required a higher level of care. Findings include: 1. A review of R1's (admitted in 2023) medical record revealed documentation dated within 90 calendar days before R1's date of admission, signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 2. In an interview, E1 reported R1's medical practitioner was on the facility's premises the previous day when E1 realized the date the document was originally signed was incorrect. E1 reported E1 gave the document back to the medical preactitioner to sign but never received it back. E1 acknowledged there was no documentation in R1's medical record to demonstrate R1 was appropriate for admission into the assisted living facility.