Health inspection·December 8, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to reconcile, dispose, and account for a discontinued controlled medication (medications that are regulated by the government due to the likelihood for being misused and high risk for abuse) to prevent drug diversion (the illegal distribution or abuse of prescription drugs) for one resident (Resident 1). As a result of this deficient practice, six tablets of the controlled medication went missing, and there was an inaccurate count of the controlled medication. Findings: Resident 1 was re-admitted to the facility on [DATE] with the diagnoses including chronic respiratory failure with hypoxia (a condition where there is not enough oxygen in the body) and dependence on ventilator (breathing machines that keep lungs working) according to the facility's admission Record. An abbreviated survey for a facility reported incident was conducted on 11/16/23. During an interview and concurrent observation with the Assistant Director of Nursing (ADON) on 11/16/23, at 9:20 A.M., the ADON showed a large, white container in the medication room. The ADON stated non-controlled medications (medications prescribed by a physician and over the counter medications) were disposed in the container and sealed once full. The ADON further stated controlled medications were given to the Director of Nursing (DON) for disposal. The ADON then went to the DON's office and the DON showed a locked drawer. The DON unlocked the drawer, and it contained one card of Alprazolam 0.5 milligrams (mg) labeled with Resident 1's name. The medication count sheet titled, Controlled Drug Record, was reviewed with the DON. The count sheet did not have signatures under dose given, but had two signatures dated 7/6/23, indicating 30 doses were received. During an observation of Resident 1 on 11/6/23, at 9:27 A.M., Resident 1 was in bed with eyes closed. Resident 1 was observed with a tracheostomy (an opening on the neck with a tube to help with breathing) connected to a ventilator. An interview and concurrent record review was conducted with Licensed Nurse (LN) 1 on 11/16/23, at 10:43 A.M. LN1 stated discontinued controlled medications were counted and compared with the count sheet to ensure accuracy. LN 1 stated any inaccuracies were reported to the DON. LN 1 stated Page 1 of 2 555871 555871 12/08/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few controlled medications were given to the DON for disposal. LN 1 checked Resident 1's medication administration record with LN 3. LN 1 and LN 3 confirmed that Resident 1 did not receive Alprazolam for the months of October and November this year (2023) because the medication was already discontinued. During an interview on 11/16/23, at 10:50 A.M., with LN 2, LN 2 stated discontinued controlled medication were logged in a binder in the DON's office and handed to the DON personally for disposal. An interview was conducted on 11/16/23, at 1:59 P.M., with LN 5. LN 5 stated on 11/9/23 he witnessed LN 6 in the medication room holding a controlled medication card for disposal. LN 5 informed LN 6 that controlled medications were to be given to the DON. LN 5 stated he notified the charge nurse (LN 4) of the incident. An interview was conducted on 11/16/23, at 4:23 P.M., with LN 4. LN 4 stated as he was going to the medication room, LN 6 was heading towards the medication cart. LN 4 stated LN 6 handed the medication card with Resident 1's name, observed 24 tablets of Alprazolam on the card, and the count sheet had 30 tablets remaining. LN 4 stated LN 6 indicated there was another medication card that was disposed in the trash. LN 6 was not able to identify which trash can the medication card was disposed. LN 4 stated all trash cans and outside dumpster were searched and there was no other medication card found. During an interview on 11/16/23, at 12:05 P.M., with the ADON, the ADON stated Resident 1 was re-admitted on [DATE] and did not have an order for the controlled medication (Alprazolam). An interview was conducted on 12/4/23, at 4:48 P.M., with the facility's pharmacist. The pharmacist stated it was his expectation for licensed nurses to give discontinued controlled medications to the DON as soon as possible to prevent drug diversion. During an interview on 12/8/23, at10:18 A.M., with the DON, the DON acknowledged the discontinued controlled medication should not be in the medication cart due to the risk of diversion. A review of the facility's undated policy and procedure (P&P) titled, Nursing Clinical .Controlled Medications-Storage, Reconciliation and Disposition, the P&P indicated, .Controlled Drugs that have been discontinued shall be given to the Director of Nursing and must be secured in a double locked container/space until disposed .Controlled medications remaining in the facility after the order has been discontinued are retained in the facility in a securely locked area with restricted access until destroyed by a DEA representative; destroyed by the facility's DNS or authorized designee, and consultant pharmacist . 555871 Page 2 of 2