The Harbor Lighthouse II

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount and frequency of assisted living services being provided to the resident, for one of two residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed a service plan for personal care services (dated in May 2023). The service plan stated "Hygiene/ADLs: Daily unless indicated otherwise... Documented in file..." However, the service plan did not include the amount and frequency of this assisted living service being provided to R1. 2. A review of R2's medical record revealed an activities of daily living (ADL) sheet for August 2023. The ADL sheet stated "Full Bath: 2 Week... Partial Bath: Daily... Shampoo: 2 Week... Shave: 2 Week... Assist with clothing: Daily... Oral Care: Daily... Hand Nail Care: 1 Week... Foot Nail Care: 1 Month..." 3. In an interview, E1 reported the nurse made an error on R2's service plan. E1 acknowledged the amount and frequency of assisted living services being provided to R2 was not included on R2's service plan.