GARDENS OF SUN CITY, THE

Based on record review and interview, the manager failed to ensure a caregiver documented services provided to a resident in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as the Department was unable to verify required services were provided to a resident.

Findings include:

1. A review of R1's medical record revealed a current service plan for directed care services. The service plan indicated R1 required "[Daily] Bathing, assistance...Resident will be clean and odor free daily. Effective March 7, 2023." Further review of R1's medical record revealed activities of daily living (ADL) logs. A review of R1's May 2023 ADL log revealed blank gaps indicating R1 did not receive daily bathing assistance on May 18, 23-24, and 31, 2023. Additionally, the ADLs did not include documentation indicating R1 refused or did not require this service.

2. A review of R2's medical record revealed a current service plan for personal care services. The service plan indicated R2's required "Bathing Stand By Assist...Resident will receive physical assistance to bathe as well as to transfer in and out of shower as needed. Effective May 30, 2023." Further review of R2's medical record revealed ADL logs. A review of R2's November 2023 ADL log revealed blank gaps indicating R2 did not receive bathing assistance on November 28 and 31, 2023. Additionally, the ADLs did not include documentation indicating R2 refused or did not require this service.

3. In an interview, the Compliance Officer asked E3 if R1 and R2 were out of the facility on the aforementioned dates. E3 stated, "No, caregivers didn't document services." E3 acknowledged a caregiver did not provide assistance with activities of daily living according to R1's and R2's service plan.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for two of two residents sampled. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency.

Findings include:

1. A review of R1's, R2's, R3's, R4's, R5's, R6's and R7's medical records revealed no documentation to indicate R1, R2, R3, R4, R5, R6 and R7 were oriented to exits from the assisted living facility.

2. In an interview, E1 acknowledged the manager failed to ensure R1's, R2's, R3's, R4's, R5's, R6's and R7's medical records contained documentation of R1's, R2's, R3's, R4's, R5's, R6's and R7's orientation to exits from the assisted living facility.

Based on documentation review and interview, the manager failed to ensure a disaster plan review required in (A)(2) was documented to include the time of the disaster plan review; the name of each employee or volunteer who participated in the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement. The deficient practice posed a risk if employees were unable to implement a disaster plan.

Findings include:

1. A review of facility documentation revealed documentation of a disaster plan review. However, the documentation did not include the time of the disaster plan review; the name of each employee or volunteer who participated in the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement.

2. In an interview, E1 acknowledged the manager failed to ensure the disaster plan review required in (A)(2) was documented to include the time of the disaster plan review; the name of each employee or volunteer who participated in the disaster plan review; a critique of the disaster plan review; and if applicable, recommendations for improvement.