Health inspection·August 3, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, and record review, the facility failed to ensure an account of all controlled drugs in order to minimize loss or diversion of narcotics when narcotic return bin(s) were not emptied on a daily basis. Residents Affected - Few This failure resulted in one tablet of tramadol (narcotic pain medication) 50 mg (milligram, unit of measure) not being accounted for and had the potential for narcotics to be diverted from the facility. Findings: On 6/20/23 the facility reported to the Department a loss of one tramadol 50 mg tablet. The report indicated, on 4/25/23, at 4:13 a.m., Licensed Nurse (LN 1) documented returning one tramadol 50 mg tablet to the facility's Nursing Station 3's (NS 3) external Pyxis (automated system that automates the distribution, management and storage of medications) return bin. The tramadol tablet was not found in the return bin when it was emptied on 6/6/23 by pharmacy technicians. During an interview on 6/28/23 at 10:30 a.m. with Director of Nursing (DON), DON confirmed the missing tramadol 50 mg tablet was unaccounted for and stated the tramadol should have been in the NS 3's return bin on 6/6/23. During an interview on 6/28/23 at 11:41 a.m. with Pharmacy Technician (PT), PT stated, tramadol 50 mg tablet should have been returned to the return bin on 4/25/23, but it was not found when checking NS 3's return bin on 6/6/23. PT stated, the return bin should have been emptied on 4/25/23 and it was not. PT further stated, according to the facility ' s policy return bins are supposed to be emptied every day, but they are not. During an interview on 6/28/23 at 11:51 a.m., with Diversion Program Manager (DPM), DPM stated, tramadol 50 mg was documented as being returned to NS 3's return bin on 4/25/23. When the return bin was emptied on 6/6/23, the tablet was not found in the bin. DPM was unable to recall the last time the return bins were emptied, and stated, They should be emptied daily. During a concurrent interview and document review on 6/28/23 at 12:03 p.m. with Director of Pharmacy (DOP), DOP reviewed documentation when the narcotic return bin was emptied during the year 2023. The documentation indicated, NS 3's return bin was emptied on 2/4/3, 3/22/23, and 4/18/23 . DOP stated the return bin should be emptied every day, and it was not. During a review of the facility ' s internal guidance document titled, Return Bin Instructions, Page 1 of 2 056200 056200 08/03/2023 Community Memorial Continuing Care Center 1306 Maricopa Highway Ojai, CA 93023

F 0755 undated, the document indicated, It is the expectation that all return bins are opened with a witness, and checked for returns daily. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056200 Page 2 of 2