Inspection Details

Inspection #
INSP-0058288
Inspection Date(s)
2/29/2024
Status
Complete
Inspection Type
Compliance (Annual)
Worksheet Type
Assisted Living Home
Certificate Number
AL11604H
Location Type
โ€”

Initial Comments

The following deficiency was found during the on-site compliance inspection conducted on February 29, 2024:

Statement of Deficiency

1 deficiency 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, record review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a refrigerator in the kitchen which was accessible to resident. Inside the refrigerator, the Compliance Officers observed a lock on the upper compartment in the door. However, the compartment had been left unlocked. Inside the compartment, the Compliance Officer observed "Morphine Sulfate," "Bisacodyl," and "Insulin Lispro." Addtionally, on a lower shelf in the door of the refrigerator, on the same shelf as food items, the Compliance Officers observed "Guaifenesin Chest Congestion Relief," and "DayTime Cold and Flu." 2. In an interview, E1 and E2 acknowledged medications stored by the assisted living facility had not been stored in a locked area.
Plan of Correction
Permanent Correction Date
2024-03-14