Wrenette's Place

The facility failed to ensure that all residents had a care plan completed annually. Specifically, Resident #1's care plan was outdated, and the Administrator could not locate the 2024 care plan or recall when it was last completed.

The facility failed to ensure documentation of follow-up for physician orders and treatments. For Resident #1, the facility failed to follow up on a laboratory order for a CMP panel, and the Administrator was unaware the lab work was due.

The facility failed to ensure medications were administered and recorded as prescribed. For Resident #1, there was no documentation of Metamucil administration for several weeks, and a handwritten note indicating medication discontinuation lacked a date. Additionally, the pharmacist had not received a new order for the medication.

The facility failed to complete required resident assessments within 30 days of admission and annually thereafter. These assessments must include comprehensive information regarding the resident's physical, cognitive, and psychosocial status, as well as dietary and medication needs.

The facility failed to maintain readily retrievable records for controlled substances by failing to properly document the receipt, administration, and disposition of Lorazepam for Resident #1. Specifically, controlled substance count sheets (CSCS) lacked essential information such as dates received, quantities received, doses given, amounts remaining, and required signatures. Additionally, some medication administration records (MARs) showed gaps in documentation for scheduled doses.

The facility failed to maintain readily retrievable records for controlled substances by failing to document the administration and disposition of medications. Specifically, for one resident, there was no documentation of the administration of Lorazepam 1mg for the month of May 2024.

The facility failed to maintain current building sanitation and fire/building safety inspection reports. Specifically, the most recent sanitation report was dated February 2019, and the Administrator had not scheduled a new inspection due to pending bathroom repairs.

The facility failed to ensure that fingerstick blood sugar (FSBS) checks were completed and documented according to physician orders. For two of the two residents sampled, required FSBS checks three times a day were not properly implemented or recorded.

The facility failed to ensure that medication administration was in accordance with physician orders. Specifically, a resident was being administered Lisinopril at an incorrect dosage compared to the prescribed orders, and conflicting medication bottles were found on hand.

The facility failed to ensure that non-licensed personnel were competency validated by return demonstration for LHPS tasks, specifically regarding ambulation assistance with canes/walkers, transfers, and fingerstick blood sugar monitoring. Record reviews for Staff A and Staff B showed no documentation of required competency validations for these tasks.