Sunshine Residential Care Home.

“Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two 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 current service plan dated February 12, 2025. The service plan reported the following: - "Incontinent check: Every 2-3 hrs; as needed" - "Catheter Care: empty drainage bag twice a day and as needed" 2. Review of R1's medical record revealed an ADL record for the month of February 2025 where incontinent checks and catheter care were left blank. 3. Review of R2's medical record revealed a current service plan dated August 2024. The service plan reported the following: -"Brush teeth daily" -"Comb hair daily" -- "Incontinent check: Every 2-3 hrs; as needed" 4. Review of R2's medical record revealed an ADL record for the month of February 2025. The ADL log revealed incontinent checks were left blank for February. 5. In an interview, E1 acknowledged the caregiver did not document the services provided in R1's and R2's medical records.”

“Based on record review and interview, the manager failed to ensure a resident medical record contained documentation of a medication administered to a resident that included the date and time of administration; the name, strength, dosage, and route of administration; the name and signature of the individual administering the medication; and an unexpected reaction a resident had to the medication, for one of two residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed no documentation of a February 2025 medication administration record (MAR). Based on the resident's date of acceptance, this documentation was required. 2.A review of R1's service plan dated August 14, 2024 documented R1 received personal care services and medication administration services. 2. In an interview, E1, acknowledged R1 received medication administration and the February 2025 MAR was not available for review.”