Follow-up·May 25, 2021

On 5/25/2021 Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced Case Management visit and met with Executive Director, Ashlee Sloan (AS). LPA Walters conducted a virtual complaint visit at this facility on 9/22/20. On that date, LPA toured the facility virtually, by way of AS and observed a basket of medications in the cabinet of the Memory Care Medication room. Per AS these medications were to be destroyed. (pictures on file). LPA requested and reviewed the Centrally Stored Medication Logs of the residents whose medication was to be destroyed, The facilities medication destruction policy, along with the pictures of the medications that were to be destroyed. LPA requested that AS provide centrally stored logs and/or orders to destroy medication for R1 and R2. The Administrator was unable to locate documents. AS confirmed that they understand that all records should be accessible for 3 years as required per regulation. LPA learned the following: Per record review, Resident R1 moved out of the facility on 4/6/2020 and At the time of inspection R1's medication had not been destroyed and was being stored in the facility as of 9/22/20. Resident R2's moved out of the facility on 7/1/2020 and their medication had not yet been destroyed and was being stored in the facility as of 9/22/20. Upon learning this, AS had all dc'd medication destroyed. LPA conducted subsequent visits on 5/14/21 and 5/25/21 and confirmed that dc'd medications were destroyed within 30 days. LPA reviewed the facility Medication Destruction Policy, which states that all medications which are no longer in use by the resident will be destroyed. continued on 809 C Continued from 809 Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties . ,