Pecan Care Concepts at American Orchards

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the medication room located in the common area in the front of the building. The medication room was unlocked, and the door was left open. 2. In an interview, E1, E2, and E3 acknowledged the medication room was unlocked and the door was left open by E2.

Based on an observation and interview, the manager failed to ensure a means of exiting the facility controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed eight resident bedrooms which had doors leading from the residents' rooms to outside of the facility. The Compliance Officer observed the doors had mechanisms to alert employees of the egress of a resident from the facility, however the mechanisms were not working. 2. During the environmental inspection of the facility, the Compliance Officer observed multiple doors leading for the two common areas to the outside back patio. The Compliance Officer observed the doors had mechanisms to alert employees of the egress of a resident from the facility, however the mechanisms were not working 3. In an interview, E4 acknowledged eight bedrooms for residents of the facility and the doors from the common areas had mechanisms to alert employees of the egress of a resident from the facility, however the mechanism were not working.

Based on record review and interview, the manager failed to ensure a residency agreement included the policy and procedure for an assisted living facility to terminate residency, in compliance with A.A.C. R9-10-807(G), for three of three resident records reviewed. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed residency agreements. The residency agreements stated "...The Community may also terminate this Agreement after providing a 14-day written notice to the Resident or the Resident's representative for any of the following reasons: ...(b) The Resident's non-compliance with this Residency Agreement or community rules ...". 2. In an interview, E1 acknowledged R1's, R2's, and R3's residency agreements did not include the correct provisions for an assisted living facility to terminate residency.

Based on record review, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of three resident records reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services and medication administration. 2. A review of R1's medical record revealed a signed list of medication orders dated March 21, 2024. The list included "Sertraline HCI Oral Tablet 25 MG ... increase to 50mg qd (ok 25mgx2 until 50mg avail)". 3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated March 2024. The MAR was initialed to indicate Sertraline 25 MG (two tablets) and Sertraline 50MG, were both administered on March 22 at 8am. 4. In an interview E1 reported the documentation was an error and the medications were not administered as documented on March 22, 2024 at 8am. 5. In an interview, E1 acknowledged a medication administered to a resident was not correctly documented in the resident's medical record.