Inspection Details

Inspection #
INSP-0055222
Inspection Date(s)
9/26/2024
Status
Complete
Inspection Type
Compliance (Annual)
Worksheet Type
Assisted Living Home
Certificate Number
AL9242H
Location Type
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Initial Comments

The following deficiencies were found during the on-site compliance inspection conducted on September 26, 2024:

Statement of Deficiency

2 deficiencies found
Deficiency #1
✓ Plan Provided
Rule
F. When medication is stored by an assisted living facility, a manager shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;
Evidence
Based on observation, documentation review and interview, the manager failed to ensure medication was stored in a locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1. The Compliance Officer observed a mediset in a cabinet adjacent to the kitchen and the cabinet was unlocked and unsecured. The mediset was full of unidentifiable medication. 2. Documentation established a policies and procedures section titled "Storage & Control Of Medication". This section had a subsection titled "Stored Medications". A subsection of the "Stored Medications" section contained the following instruction: "All medications stored by the Facility will be maintained in a locked area used only for medications". 3. In an interview, E1 confirmed that a mediset was in a cabinet adjacent to the kitchen and the cabinet was unlocked and unsecured. The mediset was full of unidentifiable medication. E1 also confirmed that documentation established a policies and procedures section titled "Storage & Control Of Medication". This section had a subsection titled "Stored Medications|. A subsection of the "Stored Medications" section contained the following instruction: "All medications stored by the Facility will be maintained in a locked area used only for medications".
Plan of Correction
Permanent Correction Date
2024-09-26
Deficiency #2
✓ Plan Provided
Rule
D. A manager shall ensure that: 4. A resident's sleeping area: b. Is not used as a passageway to a common area, another sleeping area, or common bathroom unless the resident's sleeping area: i. Was used as a passageway to a common area, another sleeping area, or common bathroom before October 1, 2013; and ii. Written consent is obtained from the resident or the resident's representative;
Evidence
Based on observation and interview, the manager failed to ensure that a resident's sleeping area was not used as a passageway to a common area. The deficient practice posed a potential privacy rights violation to the residents. Findings include: 1. The Compliance Officer observed that R1's room served as a passageway to E1's office. There was no other way to enter the office. 2. In an interview, E1 confirmed that R1's room served as a passageway to E1's office and that there was no other way to enter the office.
Plan of Correction
Permanent Correction Date
2024-09-30