Touch of Love Assisted Living

Based on record review, observation and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services dated April 25, 2024. This service plan stated the following service was needed: "Skin Care: Hydrate skin with lotion or oil ." However, documentation was not available indicating this service was provided. 2. Review of R2's medical record revealed a current written service plan for personal care services dated April 20, 2024. This service plan stated the following service was needed: "Skin Care: Hydrate skin with lotion or oil. Turn resident every 2-3 hours to prevent skin breakdown or pressure." However, documentation was not available indicating these services were provided. 3. During an interview, E1 acknowledged R1's and R2's medical records did not include documentation of skin care.

Based on documentation review, observation, and interview, the manager failed to ensure there was a 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, that provided access to an outside area, and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the facility tour, the Compliance Officer observed the door leading out to the backyard from R2's bedroom. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door was not equipped with a device that alerted caregivers of the egress of a resident. 3. In an interview, E1 reported that the camera in R2's bedroom alerted employees of the egress of a resident from the facility, however, the monitor screen for the camera did not show the door or make sound when the door was opened.