Inspection Details

Inspection #
INSP-0074506
Inspection Date(s)
8/30/2023
Status
Complete
Inspection Type
Compliance (Annual)
Worksheet Type
Assisted Living Home
Certificate Number
AL11206H
Location Type
โ€”

Initial Comments

The following deficiency was found during the on-site compliance inspection conducted on August 30, 2023:

Statement of Deficiency

1 deficiency found
Deficiency #1
✓ Plan Provided
Rule
C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and
Evidence
Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan dated August 1, 2023 for personal care services. The service plan stated the following service was to be provided to R1: "toileting...catheter care empty bag twice a day". 2. A review of R2's medical record revealed an activities of daily living (ADL) document for August 2023. However, the aforementioned service was only documented as being completed once a day. 3. During an interview, E1 acknowledged R2's medical record did not include documentation of the service being provided twice a day. E1 reported the service was provided as indicated in the service plan.
Plan of Correction
Permanent Correction Date
2023-08-30