Mccormick Ranch Assisted Living Home, LLC

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated June 7, 2023 for directed care services. The service plan listed the following services to be provided for R1: -"Dressing: Requires full assistance from caregiver with clothing selection and/or dressing daily"; and -"Grooming: Requires full assistance from caregivers daily and as needed with Oral hygiene, Comb hair, Moisturize, Nail care." 2. Further review of R1's medical record revealed activities of daily living logs (ADLs) for May and June 2023. R1's May and June 2023 ADLs indicated R1 received assistance with "Grooming AM" and "Grooming PM" on May 1-31, 2023 and on June 1-20, 2023. However, R1's ADLs revealed no documentation to indicate R1 received assistance with "clothing selection and/or dressing" in May or June 2023. 3. In an interview, E1 reported R1 was provided with assistance with selecting clothing and dressing every day in May and June 2023. E1 reported assistance with dressing was provided with morning and evening grooming. However, E1 acknowledged dressing and grooming were listed separately in R1's service plan, and dressing services provided to R1 in May and June 2023 were not documented in R1's medical record. 4. A review of R2's medical record revealed a service plan dated March 24, 2023 for directed care services. The service plan listed the following services to be provided for R2: -"Dressing: Requires full assistance from caregiver with clothing selection and/or dressing daily"; -"Grooming: Requires full assistance from caregivers daily and as needed with Oral hygiene, Comb hair, Moisturize, Nail care"; -"Toileting: Resident is incontinent. Observe skin care"; and -"Skin Care: Skin check after every shower or after incontinence care...Incontinence care TID and as needed." 5. Further review of R2's medical record revealed ADLs for May and June 2023. R2's May and June 2023 ADLs indicated R2 received assistance with "Grooming AM" and "Grooming PM" on May 1-31, 2023 and on June 1-20, 2023. However, R2's ADLs revealed no documentation to indicate R2 received assistance with "clothing selection and/or dressing" in May or June 2023. R2's May and June ADLs also revealed no documentation to indicate R2 received assistance with incontinence care or skin care in May or June 2023. 6. In an interview, E1 reported R2 was provided with assistance with selecting clothing and dressing every day in May and June 2023. E1 reported assistance with dressing was provided with morning and evening grooming. However, E1 acknowledged dressing and grooming were listed separately in R2's service plan, and dressing services provided to R2 in May and June 2023 were not documented in R2's medical record. E1 also reported R2 was provided with incontinence care

Based on documentation review, record review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, the means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of R1's and R2's medical records revealed service plans indicating R1 and R2 received directed care services. 3. During the environmental inspection of the facility, the Compliance Officer observed a sliding door leading from the dining area to the back yard. The door had a mechanism to alert employees of the egress of a resident from the facility, however the mechanism did not sound when the Compliance Officer opened the door. The Compliance Officer observed the outside area in the backyard allowed residents to be at least 30 feet away from the facility. The Compliance Officer also observed an unlocked gate in the north eastern corner of the backyard, which opened to the front yard, adjoining a cul-de-sac. 4. In an interview, E1 acknowledged the device to alert employees of the egress of a resident from the facility to the outside area through the back door was not in working order. E1 also acknowledged the gate in the facility's back yard did not control or alert employees of the egress of a resident from the facility. E1 acknowledged the back door and back yard gate were not controlled and did not alert employees of the egress of a resident from the facility.