Shea Manor Assisted Living Home

Based on the record review and interview, the manager failed to ensure that a caregiver or assistant caregiver provided assistance with activities of daily living according to the resident's service plan for two of the two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated February 28, 2025. R1's service plan indicated R1 required assistance with: - Check nails daily and clean PRN, and ; - Dressing Assistance required. 2. A review of R1’s activities of daily living (ADL) document revealed that 'Nail care' and "dressing" were not listed in R1's ADL. 3. A review of R2's medical record revealed a service plan dated May 28, 2025. R2's service plan indicated R2 required assistance with: - Check and clean nail daily and PRN, and; - Dressing dependent. 4. A review of R2’s activities of daily living (ADL) document revealed that ' Nail care" and "Dressing" were not listed in R2's ADL. 5. In an interview, E1 acknowledged that R1's and R2’s documentation of services provided did not reflect what was on the service plan. Technical assistance was provided on this rule during the compliance inspection conducted on January 1, 2023

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required intermittent nursing services or restraints, for one of two residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R2's medical record revealed a document titled "Consent for Resident's Stay in Facility" dated May 1, 2024. This document included documentation indicating R2 did not require continuous medical services and continuous nursing services, however, did not address intermittent nursing services or restraints as required. Based on R2's acceptance date, this documentation was required. 2. In an interview, E1 acknowledged R2 did not provide documentation signed by a medical practitioner or a registered nurse stating whether the resident required intermittent nursing services or restraints.

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. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door leading out to the backyard did not control or alert employees of the egress of a resident from the facility. 3. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.