Silver Birch of Midtown

Based on observation, record review and interview, for one resident reviewed, the manager failed to ensure a resident had a written service plan which 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 residents if the service plan did not include documentation of the resident's condition and services to be provided for the resident. Findings include: 1. In record review, R1's medical record (received directed care and medication administration services) included documentation from R1's medical practitioner, dated March 27, 2025, that stated "The patient is a 66 year old... with a past medical history of dementia, behaviors, and frequent UTIs..." 2. In record review, R1's medical record included documentation R1 was sent to the hospital on April 8, 2025, and an "Internal incident Report" documented, "... found... on floor by ... bed... had just fallen... looked very weak and was shaking... 911 was called..." The record included "Emergency Department Patient Instructions," dated April 8, 2025, which documented a discharge diagnosis of "UTI (urinary tract infection), Fall at home, and Dementia." 3. In record review, R1's service plan dated April 7, 2025, did not include documentation of R1's history of UTI infections, and related services to be provided. 4. During an interview, E1 and E2 acknowledged the resident's service plan did not include documentation of the resident's medical or health problems (history of UTIs), as required.