D · No harm, potential for more than minimal, isolatedOctober 24, 2022
Based on observation, interview and record review, the facility failed to develop and implement a plan of care for one of one sampled resident's (Resident 23) prosthetic (artificial device to replace a missing body part) eye. This failure resulted in the staff being unaware of the plan of care for Resident 23's missing eye. Findings: During an interview on 10/19/22, at 6:52 PM, with Family Member (FM) 1, FM 1 asked about the resident's prosthetic eye. FM 1 stated, when she last visited, Resident 23 was not wearing the prosthetic eye. During a concurrent observation and interview on 10/20/22, at 2:02 PM, with Social Services Manager (SSM), in Resident 23's room, Resident 23 was noted not wearing the prosthetic eye. …