Cami Senior Living, LLC

Based on observation, documentation review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. Review of Department documentation revealed the facility is licensed to provide directed care services. 2. The Compliance Officer observed ambulatory residents. 3. The Compliance Officer observed the open laundry room door which led to the unsecured garage door. The following medications were observed in a refrigerator in the garage: Ibuprofen 100/5 ML Two bottles of Acetamin Sol 160/5 ML Two bottles of Lactulose Sol 10 GM/ 15 4. Review of the facility policy and procedures revealed a policy titled, "Medication Including Opioids and Narcotics” which stated, “3. Medication stored by the facility will be locked in the medication storage area.” 5. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 6. This is a repeat deficiency from the inspection conducted on February 8, 2023.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of Department documentation revealed the facility is licensed to provide directed care services. 2. The Compliance Officer observed ambulatory residents. 3. The Compliance Officer observed the door leading to the laundry was open and the Compliance Officer was able to push the door open. Inside the laundry room the following were observed: One bottle of Xtra laundry detergent, A spray bottle of Windex, A bottle of Fabuloso multi purpose cleaner, and Ensueno max fabric softener. 4. The Compliance Officer observed a door leading out to the garage door from the laundry room. In the garage the following were observed: Zep Instant Spot & Stain Remover, Goof Off pro strength remover, A spray can of Raid, A spray can of Scrubbing Bubbles, Clear savings Bleach, Four 2.37 gallons of ensueno, and Two 1.64 gallons of Fabuloso. 5. Review of the facility policy and procedures revealed a policy titled, “Environmental and Physical Plant Safety” which stated, “15. Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas, dingins, areas, and medications and are inaccessible to residents.” 6. In an exit interview, the findings were reviewed with E3, and no additional information was provided. 7. This is a repeat deficiency from the inspection conducted on February 8, 2023.

Based on record review and interview, the manager of an assisted living home who contacted an emergency responder on behalf of a resident failed to provide to the emergency responder a written document that included all required documentation, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed an incident report dated May 19, 2024. The incident report revealed R1 had an accident, emergency, or injury, the facility contacted an emergency responder, and R1 was taken to the hospital. However, the documented information provided to the emergency responder did not include the following: -The reason or reasons the emergency responder was requested on behalf of R1; -The name, address and telephone number of the resident's current pharmacy; -The point-of-contact information for the assisted living home, including the cell phone number and email address; and -A copy of R1's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living home to plan for R1's discharge. 2. In an interview, E1 reported E1 was not familiar with this statute. E1 had not yet updated the facility documentation to include the required information but reported the information was provided to the paramedic personnel.

Based on record review and interview, the manager failed to provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of four employees reviewed. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. Review of E4's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E4's hire date, this documentation was required. 4. In an interview, E1 acknowledged E4 did not provide documentation of freedom from infectious TB as specified in R9-10-113.