complaint·August 20, 2024

The investigation revealed the following. Regarding Allegation: Staff are mishandling the residents’ medications- It is alleged staff did not document the destruction of medications, ensure medications and narcotics were centrally stored and inaccessible to persons other than employees responsible their supervision, and missing medications. Five (5) out of the five (5) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. Interviews with staff revealed on or around 8/14/2024, several resident medications which were scheduled to be destroyed, were observed to be secured in the facility medications cart but, still needed to be logged for destruction. Facility management became aware on 8/14/24 and medications were logged for destruction and destroyed. Interviews with residents revealed staff provides residents with medications as needed and residents receive their medications as ordered. Per Title 22, Incidental Medical and Dental Care-87454(i)(1)(2)(3)(4)- Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed. (4) The date of destruction. LPA Ramirez reviewed medications destruction log for twenty (20) residents and observed the logs to list the name of the resident, prescription number and name of the pharmacy, name of drug, strength and quantity destroyed, and date of destruction. LPA Ramirez reviewed and obtained copies of July 2024 and August 2024 Narcotic Shift Count log for the facility memory care unit and assisted living. LPA Ramirez did not observe any documented discrepancies on these logs. During tour of facility, LPA Ramirez observed memory care medications room to be inaccessible to residents in care and observed one (1) staff to have sole custody of the key required to open the medications room door. LPA Ramirez observed the assisted living medications cart to be inaccessible to residents in care and observed one (1) staff to have sole custody of the key required to access medications cart. LPA Ramirez toured the facility health center room located on the 3 rd floor. Room was observed to be inaccessible to residents in care. LPA Ramirez did observe resident charts in this room and did not observe medications in this room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies were cited today. Exit interview was conducted. A copy of this report was provided.