Paradise Oasis

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of four residents sampled. Findings include: 1. A review of R3's medical record revealed a currenr service plan which indicated R3 received medication administration. Further review revealed a medication administration record (MAR) dated June 2024, which indicated R3 was being administered "Pantoprazole Sodium 40MG" once per day. 2. A review of R3's medical record revealed evidence of an order for Pantoprazole Sodium 40MG to be administered once per day was unavailable for review. 3. In an interview, E1 acknowledged an order for Pantoprazole Sodium 40MG to be administered once per day was not available for review.

Based on record review and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication administered to the resident, for one of four residents sampled. Findings include: 1. A review of R3's medical record revealed a current service plan which indicated R3 received medication administration. Further review revealed a medication administration record (MAR) dated June 2024, which indicated R3 was being administered "Pantoprazole Sodium 40MG" once per day. 2. A review of R3's medical record revealed an order for numerous medications to be administered to R3. However, evidence of an order for Pantoprazole Sodium 40MG to be administered once per day was unavailable for review. 3. In an interview, E1 agreed an order for R3 to receive Pantoprazole Sodium 40MG once per day was not available for review.

Based on documentation review, record review, and interview, the manager failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. Review of randomly selected staff personnel records revealed that E4, who was hired on August 28, 2023, and E5, who was hired on April 29, 2024, had no documentation of completing fall prevention and fall recovery training as required. 2. During an interview, E1 and E2 acknowledged that E4 and E5 had not completed the required fall prevention and fall recovery training.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the required information from a home health agency, for one of one resident's medical record reviewed who had been receiving home health services. Findings include: 1. In an interview at the beginning of the compliance inspection, E2 reported that R3 had several probably stage two wounds that were being treated by home health twice a week and as needed since May (2023) 2. Review of R3 medical record found no documentation, as required, each time home health came to the facility for the care of these wounds. 3. In an interview, E2 reported there was "no" documentation. E2 reported, "they didn't leave anything".

Based on record review and interview, the manager failed to ensure that a service plan for a resident receiving personal care services included the treatment of pressure sores and infections, which posed a health and safety risk; for one of one sampled resident. Findings include: 1. In an interview at the beginning of the compliance inspection, E2 reported that R3 had several wounds that were probably stage two wounds that were being treated by home health twice a week and as needed since May (2023). The wounds were located on the left heal, scrotum, and buttock. 2. Review of R3's medical record found an order dated May 10, 2023 from the medical practitioner for wound care treatment. 3. The current service plan, dated May 9, 2023, stated the resident required personal care and medication administration service. This service plan had been signed by the nurse and all other required individuals who reviewed the service plan . The service plan included skin maintenance to prevent skin issues, however, there was no documentation, as required, about R3's skin issues and the treatment of these skin issues, that had been identified by a medical practitioner in an order about the same time the service plan was updated. 4. During an interview, E2 acknowledged the current service plan failed to address R3's skin issues and the treatment of these wounds.