Complaint·July 30, 2024

Upon entry, LPA observed the medication room as clean and organized as purposed. A camera is installed to video record Staff activities. All Resident medications were observed as secured in locked cabinets; no medications were observed as loose and/or outside secured containment. LPA, with the assistance of the Staff Wellness Director (S1) and Staff Wellness Coordinator (S2) conducted an audit of the medications for sixteen (16) Residents. A comparison of each Resident's medication control log with their corresponding medications resulted in LPA finding no discrepancies. LPA gathered Medication Destruction Records, reviewed the facility's Medication Destruction Records Log finding no discrepancies. All expired medications, used syringes, and all other pharmaceutical waste is placed in a closed container and scheduled for bio-hazard disposal by vendor. (Market Rx) LPA interviewed S1 and S2 who stated all expired medications are tracked, recorded and scheduled for picked up by bio-waste management vendor for destruction. Staff confirms all medications are logged, dispensed to Residents, and expired medications destroyed as per facility policy and Tittle 22 regulations. Based on LPA observation, file review, and interviews, the allegation is UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. Copy of this report issued.