Incident investigation·November 29, 2023

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit in regards to an incident report that was received. LPA met with Administrator, Janelle Douglas, during today's inspection. CCL received an incident report from the facility stating that during destruction of discontinued medications facility staff observed there was 2 packs of hydrocodone missing from the medication cart. Missing medications belonged to a past resident who no longer resides at the facility. LPA interviewed administrator in which the staff member responsible for medication destruction has been terminated. An internal investigation occurred and the investigation came back inconclusive. LPA reviewed medication policies, and medication destruction policies. Facility has reported missing medications to the local police department. Administrator stated they will be working on new procedures in regards to medication destruction. If changes occur to facility policy and procedures, Administrator agrees to send a copy into CCL for review. No deficiencies cited during today's inspection. Exit interview conducted and copy of report provided.