DESERT HOME BY PLATINUM CARE HOMES

<p>Based on record review and interview, the manager failed to ensure medications were administered to a resident in compliance with a medication order, for two of two sampled residents.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. A review of R1's and R2's medical records revealed each resident had a current service plan which included medication administration.</p><p><br></p><p>2. A review of R1's and R2's medical records revealed signed lists of medication orders from each resident's primary care physician.</p><p><br></p><p>3. A review of R1's and R2's medical records revealed an electronic Medication Administration Record (eMAR), dated July 2025, for each resident. The eMARs documented the medications provided to each resident. However, both eMARs included multiple errors and omissions where medication had not been documented to have been administered in compliance with a medication order.</p><p><br></p><p>4. In an interview, E1 reported having some difficulty with their electronic health record.</p><p><br></p><p>5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>

Based on record review and interview, the manager failed to ensure each resident's written service plan accurately included the amount, type and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medications, for one of two sampled residents.

Findings include:

1. A review of R2's medical record revealed a current service plan, dated May 14, 2024, for directed care services. The service plan stated, "Basic Hydration, Offer at least 1 glass of liquid at every meal, in between meals, and throughout the day. Encourage [R2] to drink water or other beverage he/she likes every 1-2 hours throughout the day. Encourage [R2] to limit the amount of beverages that contain caffeine."

2. A review of R2's medical record revealed discharge summary from a hospital, dated the day of R2's admission. The discharge summary was electronically signed by a physician and included the following treatment order:
"Hyponatremia, -122-->128-->127-->131-->129. Labs consistent with SIADH. Continue salt tabs. Adjusted fluid restriction to 1500 ml/day."

3. A review of R2's medical record revealed a document titled, "Platinum Care Homes, Inc, Admission, Medication, Diagnosis & Treatment orders." The document was signed by a medical practioner on the day of R2's admission. The document included the order, "Special Diet & Instructions: Fluid Restriction 2 Liters/day."

4. A review of R2's medical record revealed an order to discontinue the fluid restriction was not available for review.

5. In an interview, E1 and E2 acknowledged R2's service plan did not include fluid intake monitoring as ordered.

Based on observation and interview, the manager failed to ensure medication stored by the facility was stored in a separate locked area used only for medication storage.

Findings include:

1. During an environmental inspection of the facility, the Compliance Officer observed a kitchen cabinet used to store resident medications, including Naproxen, Ibuprofen, and Melatonin, did not have a lock.

2. In an interview, E1 acknowledged medication stored by the facility was not stored in a separate locked area used only for medication storage.