Sapphire Elite Care Home LLC

Based on 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 the front door. The Compliance Officer observed front door had no mechanism to alert employees of the egress of a resident from the facility. 2. In an interview, E1, E2, and E3 acknowledged that there was no mechanism on the front door to alert staff of a resident leaving the facility.

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 used only for medication storage. Findings include: 1. During a environmental inspection of the facility, the Compliance Officer observed an unlocked drawer in the kitchen area which contain the following medications: -one tube of Hydrocort Cre 1% -one tube of Preparation Cre H -one tube of Bengay, Ultra Strength -one tube of Diclofenac Sodium Topical Gel 1%; and -five tubes of Calmoseptine 2. A review of the facility's policies and procedures manual (no date available) revealed a policy titled "Medication Management and Services Policy and Procedure." The policy stated " ...g. Storing medications properly and securely...." 3. In an interview, E1 acknowledged that the medication should have been locked way in the locked medication cabinet in the kitchen. 4. In an interview, E2 reported the Hydrocort Cre 1% belonged to one of the residents. 5. In an interview, E2 acknowledged the medications were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on an observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed risk of a potential explosion or leak of a compressed gas. Findings include: 1. During a environmental inspection of the facility, the Compliance Officer observed in R2's room, the closet contained five unsecured oxygen containers. 2. In an interview, E1 and E2 both acknowledged the five oxygen containers in R2's room closet were not secured in an upright position.