LAKE PLEASANT ASSISTED LIVING

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. Review of R1's medical record revealed a signed wound care order dated January 17, 2023. This order stated "Coccyx wound care as follows: Cleanse wound with normal saline/wound wash, pat dry, apply medihoney to wound bed. Cover with padded foam dressing. Change three times per week and PRN". However, R1's medical record did not include documentation this service was provided.

2. During an interview, E1 reported the wound care was administered three times a week and as needed and acknowledged R1's medical record did not include documentation of this service.

Based on record review and interview, the manager failed to ensure a service plan included skin maintenance to prevent and treat a pressure sore, for one of one resident reviewed receiving directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R1's medical record revealed a current written service plan for directed care services dated January 18, 2023. This service plan stated "Check pressure areas PRN, no open areas".

2. Review of R1's medical record revealed a signed wound care order dated January 17, 2023. This order stated "Coccyx wound care as follows: Cleanse wound with normal saline/wound wash, pat dry, apply medihoney to wound bed. Cover with padded foam dressing. Change three times per week and PRN".

3. During an interview, E1 reported R1 had this wound since acceptance and acknowledged R1's service plan did not include skin maintenance to treat this skin issue.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order.

Findings include:

1. Review of R2's medical record revealed a current written service plan dated October 7, 2022. This service plan indicated R2 received medication administration.

2. Review of R2's medical record revealed a signed medication order dated January 13, 2023. This medication order stated "Trazodone HCL 50mg oral tablet take 1 tablet orally nightly".

3. Review of R2's medical record revealed a January 2023 medication administration record (MAR). This MAR did not include documentation Trazodone was administered January 13th - present.

4. During an observation of R2's medications, Trazodone HCL 50mg was observed and one tab was observed prefilled in the "Bedtime" slot of R2's medication organizer.

5. During an interview, E1 reported one tab of Trazodone HCL 50mg was administered per the medication order and acknowledged R2's medical record did not include documentation the medication was administered.