The Woodlands of Dewitt

Resident A's service plan lacked detail on Elara Hospice involvement and the role of the hospice company; Resident C's service plan required blood pressure monitoring, but there was no record in the medication administration record (MAR) that this was being performed.

Resident A's medication administration record (MAR) showed Lorazepam was prescribed as needed, but the service plan lacked details on how the resident demonstrates behaviors requiring the medication or if nonpharmaceutical interventions should be used. Similar findings were noted for Resident C.

Employee training records for staff person 1 (SP1) and SP2 revealed that the administrator or designees did not evaluate medication administration competencies.

The facility did not have evidence of tuberculosis (TB) screening on record for Resident A, Resident B, and Resident C.

Resident E had bedside assistive devices attached to their bed, but the service plan lacked information regarding the purpose of use, staff responsibility for safety, maintenance schedules, and methods to prevent physical harm (entrapment, strangulation, etc.).

Resident B's care was not provided in accordance with the service plan; specifically, there was no documentation that the resident was offered or refused a shower on several scheduled dates (09/01, 09/03, 09/05, 09/10, 09/22, and 09/24).

Resident B ran out of Lumigen eyedrops.

There was no documentation or signature proving Resident B's participation in the development of their service plans during several care conferences.