Prestige Home in Arizona

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and 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. Review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the facility tour with E3, the Compliance Officer observed the door leading out to the backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device was switched off. 3. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered. Findings include: 1. Review of R1's medical record revealed a current written service plan for personal care services dated July 1, 2024, which reported that R1 received medication administration. 2. Review of R1's medical record revealed the following medication orders dated June 26, 2024: -"Pantoprazole 40mg give 1 tab by mouth twice daily"; and -"Dronedarone HCL 400mg Give 1 tab by mouth twice daily". 3. Review of R1's July 2024 medication administration record (MAR) revealed the following: -Pantoprazole 40mg was documented as administered at 9am July 1-28, however, no documentation of a second administration per day was provided; and -Dronedarone 400mg was documented as administered at 9am July 1-28, however, no documentation of a second administration per day was provided. 4. During an observation of R1's medications and weekly medication organizer, the Compliance Officer observed that it appeared that R1 was receiving both medications in the morning and before bed daily. 5. In an interview, E3 reported that both medications were administered twice daily, and acknowledged each was only documented once daily. 6. In an interview, E1 acknowledged R1's medication administration was not accurately documented in R1's medical record.