Health inspection·May 3, 2024

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 observation, interview, and record review, the facility failed to properly dispose of refused or contaminated medications in a safe, and secure manner. Residents Affected - Some This deficient practice had the potential to result in misuse, drug loss, accidental exposure and/or potential diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended) of prescription drugs. Findings: During an observation on 5/1/24 at 11:10AM, in the presence of licensed vocational nurse (LVN)1, medication cart 1 (med cart 1) and the contents within med cart 1 was observed. The first drawer from the top of med cart 1 was observed with a blue container that had a transparent lid. The container was labeled indicating pharmaceutical waste. During a concurrent observation and interview on 5/1/2024 at 11:12 a.m. with LVN 1, Med Cart 1's top drawer was observed. In the first drawer, there was a blue container, labeled pharmaceutical waste that had a transparent lid, that could be easily opened by lifting the lid, and closed by placing the lid back on. The pharmaceutical waste container had multiple unknown medications in it. LVN 1 stated, when the resident refused medications, or if medications fell on the floor, these medications were placed in this container and then discarded in the drug and medication biohazard (waste contaminated with potentially infectious agents or other materials that are deemed a threat to public health or the environment) bin located in the biohazard waste room. LVN 1 stated the medications inside the container labeled pharmaceutical waste were medications for the entire facility for residents who refused their medication, or for medication that fell on the floor. LVN1 could not state what all the medications were inside the pharmaceutical waste container or when the container was last emptied into the drug and medication biohazard bin. During an interview on 5/1/2024 at 3:19 p.m., with LVN 2, LVN 2 stated, when a resident refused their medication, LVN 2 would document the refusal in the resident's chart and discard the medication into the blue container labeled Pharmaceutical Waste. LVN 2 stated the pharmaceutical waste container should be later disposed into the large biohazard waste bin each end of the shift (Day shift 7AM-3PM, evening shift 3PM-11PM, and night shift 11PM- 7AM). During an interview on 5/1/2024 at 3:48 p.m., with the Director of Nursing (DON), the DON stated, staff would bring the controlled medications (controlled medications are substances that have an accepted medical use [medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V], have a potential for abuse, ranging from low to high, and may also lead to physical or psychological Page 1 of 2 555616 555616 05/03/2024 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dependence) with the count sheet (a document used to document and track the administration of controlled substances). The DON stated the controlled medications were locked up in the DON's office until the pharmacist came to the facility. The DON stated, both the DON and the pharmacist would document in the controlled substances disposition folder. The DON stated, for non-controlled medications (medication not tightly controlled by law because it is not considered to be dangerous or to cause addiction) for residents who were discharged or transferred to the hospital, the medications were removed from medication cart, and placed into the medication room's locked cabinet, documented, and then thrown away in the biohazard bin. The DON stated licensed nurses (LN) should not use the container labeled pharmaceutical waste, located in medication cart 1's first drawer. The DON stated the method of discarding medications in the blue container labeled as Pharmaceutical Waste increases the risk for accidental exposure and diversion of prescription drugs because it was not secured and properly disposed. During an interview on 5/3/2025 at 11:44 a.m., with LVN 4, LVN 4 stated, if a resident refused to take a medication during medication administration, LVN 4 would document the resident's refusal on the resident's medical record. LVN 4 stated putting refused medications into the labeled pharmaceutical waste container in Med cart 1's top drawer. LVN 4 could not state how long the medications in the labeled pharmaceutical waste container was there until the medications were properly discarded into the incineration bin (burns drugs and related materials rendering them to a non-retrievable state to prevent their diversion to illicit purposes). LVN 4 stated the blue container labeled Pharmaceutical Waste contained daily medications, over the counter medications, and was an accumulation from previous residents. LVN 4 stated a biohazard bin should be a proper container for safe disposal of medications. During a review of the facility's policy and procedure (P&P) titled, Disposal of Medications, and Medication-Related Supplies, dated October 2017, the P&P indicated, All medications are placed in the proper waste container per facility policy. During a review of the facility's P&P titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medications disposal, and reordered from the pharmacy if a current order exists. 555616 Page 2 of 2