SILVER BELLS II

Based on record review and interview, for one of two residents reviewed, the manager failed to ensure a resident's written service plan included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. The deficient practice posed a risk to a resident if the service plan did not include a description of the resident's condition, for which services were to be provided.

Findings include:

"Service plan" means a written description of a resident's need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident.

1. In record review, R1's medical record (received directed care services) included documentation of diagnoses as "Alzheimer's Disease.... difficulty finding words.. bruises easily, is confined to a bed or chair and unable to walk." R1's service plan did not include documentation of R1's medical and health problems.

2. During an interview, the findings were reviewed with E1 and E2, who reported R1 received directed care services, and acknowledged the service plans did not include a description of the resident's medical and health problems, as required.

Based on record review and interview, for one of two residents reviewed, the manager failed to ensure a written service plan included the amount, type and frequency of assisted living services provided to the resident, including medication administration. The deficient practice posed a health and safety risk to residents should services not be provided as required to meet the residents' needs.

Findings include:

1. In record review, R1's medical record included a "Preliminary Admission Form," dated April 22, 2016, which documented R1 was alert, oriented, confused, forgetful, had Alzheimer's, required "Mod" (Moderate) assistance with Bathing, Dressing, Oral Care, Hair care, and "Max" (Maximum) assist with medications, and activities.

2. In observation, the compliance officer observed R1 in the kitchen, being fed by E3.

3. In record review, R1's service plan, dated July 8, 2023 (received directed care services) included a "Service Plan Update/Assessment," which documented R1 was incontinent, used a wheelchair, had no skin problems identified, was encouraged to interact with others in scheduled activities. The service plan did not include the amount, type and frequency of services provided.

4. During an interview, the findings were reviewed with E1 and E2, who reported R1 received directed care services, was confined to a bed or chair, and required full assistance with activities of daily living. E1 and E2 acknowledged R1's updated service plan did not include the amount, type and frequency of services provided to the resident, including medication administration.