Rule/Regulation Violated:
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/Findings:
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. The deficient practice posed a risk to residents who were not prescribed the accessible medication.
Findings include:
1. The Compliance Officer observed Lorazepam in an unlocked refrigerator in the unlocked garage that was accessible to residents.
2. A review of the facility's policy and procedures revealed a policy titled, "Dispensing/refilling Medication" stated in a section labeled "Storage and Control of Medication" revealed, "Medications will be stored in a locked container, cabinet, or room that is inaccessible to a resident."
3. During an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.
4. This is a repeat deficiency from the compliance inspections conducted June 15, 2021 and June 21, 2022.
Summary:
The following deficiency was found during the on-site compliance inspection and investigation of complaint AZ00193414 conducted on June 25, 2024: