Inspection Details

Inspection #
INSP-0088671
Inspection Date(s)
8/9/2023 - 8/10/2023
Status
Complete
Inspection Type
Compliance (Annual)
Worksheet Type
Assisted Living Center
Certificate Number
AL8754C
Location Type
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Initial Comments

The following deficiencies were found during the on-site compliance inspection conducted on August 9-10, 2023:

Statement of Deficiency

2 deficiencies found
Deficiency #1
✓ Plan Provided
Rule
D. A manager shall ensure that: 1. A current drug reference guide is available for use by personnel members, and
Evidence
Based on observation and interview, the manager failed to ensure there was a current drug reference guide that was available for use by personnel members which posed a health and safety risk to the resident if the caregiver was unable to reference a medication a resident was taking. Findings include: 1. During the compliance inspection the compliance officer observed the facility was providing medication administration services. The facility's current drug reference guide was the Nursing 2022 Drug Handbook by Wolters Kluwer. 2. A Google search found "Nursing 2023 Drug Handbook by Wolters Kluwer and also the 2024 edition. 3. In an interview, E2 acknowledged the facility's drug reference guide was not current.
Plan of Correction
Permanent Correction Date
2023-09-01
Deficiency #2
✓ Plan Provided
Rule
A. A manager shall ensure that: 9. Soiled linen and soiled clothing stored by the assisted living facility are maintained separate from clean linen and clothing and stored in closed containers away from food storage, kitchen, and dining areas;
Evidence
Based on observation and interview, the manager failed to ensure that soiled linens stored by the assisted living facility were stored in a closed container away from food storage, kitchen, and dining areas. Findings included: 1. During a tour of the facility's memory care unit, E1, E2, and the compliance officer observed four uncovered hamper/baskets of soiled linen sitting the facility's laundry room. 2. In an interview, E1 and E 2 acknowledged the facility was storing uncovered soiled linen in the memory care unit's laundry room. Technical assistance was provided during the compliance inspection on July 6-7, 2022.
Plan of Correction
Permanent Correction Date
2023-09-01