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
โ
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
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