Shady Harbour Adult Living

The facility failed to ensure that care plans were completed annually for three sampled residents. Specifically, records for Resident #1 and Resident #2 showed care plans had not been updated for over a year, and the Administrator was unaware of these lapses.

The facility failed to properly conduct assessments following a significant change in a resident's baseline condition. Specifically, the facility must monitor residents for up to 10 days after identifying changes in factors like ADLs, weight, or behavior, and complete a formal assessment within three days of identifying a significant change.

The facility failed to ensure a resident's FL2 medical examination was updated annually. Specifically, one resident's FL2 had not been updated since April 2023, and staff were unaware of the lapse or any audits to prevent such occurrences.

The facility failed to ensure that a functional assessment of each resident is completed within 30 days of admission and at least annually thereafter to determine psychosocial, cognitive, and physical functioning.

The facility failed to ensure that a licensed pharmacist, provider, or registered nurse completed a quarterly on-site medication review. This failure was identified for 3 of 3 sampled residents.

The facility failed to ensure that annual tuberculosis tests and medical examinations were updated for all residents. Specifically, 2 of 3 sampled residents did not have updated annual documentation.

The facility failed to ensure that resident assessments were completed annually. For one of three sampled residents, the care plan had not been updated since December 2022.

The facility failed to complete annual resident care plans for multiple residents. Specifically, records for Resident #1, Resident #2, and Resident #3 showed care plans that had not been updated within the past year.

The facility failed to develop annual care plans for 3 out of 3 sampled residents. Specifically, the care plans for these residents had not been updated since August 2019, despite changes in clinical status and ongoing resident needs.

The facility failed to ensure that at least one staff person on the premises at all times had completed a cardio-pulmonary resuscitation (CPR) and choking management course within the last 24 months. Specifically, three sampled staff members (Staff A, B, and C) had expired CPR certifications. This failure placed residents at risk for potential delays in life-saving measures.

The facility failed to ensure that at least one staff person on the premises at all times had completed a CPR and choking management course within the last 24 months. A review of personnel records for three sampled staff members showed expired certifications or no documentation of recent training.