Health inspection·February 23, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 5 of 5 months (February 2022, May 2022, August 2022, November 2022, January 2023) reviewed for pharmacy services. The facility failed to have a licensed pharmacist and witnesses initial the attached pages of medication destruction inventory sheets. This failure could place residents at risk for misappropriation and drug diversion. Findings: During a record review of facility medication destruction log for the last 12 months indicated the facility had 5 medication destructions in the last year (02/23/2022, 05/26/2022, 08/24/2022, 11/18/2022, and 01/25/2023) and the pharmacist and 2 witnesses did not initial the attached sheets of the medication destruction inventory sheets. During an interview on 02/22/2023 at 1:20 pm the ADON stated the pharmacy consultant, herself and either the DON or another nurse performed the medication destruction. She stated they check each medicine off before placing them in the destruction box. She stated she was not aware that attached forms had to be initialed. She stated she didn't see any risk to the resident because she knows they were destroyed. She stated it could cause a drug diversion. During an interview on 02/22/2023 at 1:40 pm the DON stated that she was responsible for oversight of medication destruction along with the pharmacist and ADON. She stated she was not aware of the rule that attached pages of the drug destruction had to be initialed and just did it the way the pharmacist told her. She stated the risk could be a drug diversion. The DON stated she would contact the pharmacist and correct their process. During an interview on 02/22/2023 at 3:00 pm the pharmacist consultant stated she had been at the facility for 2 years and was not aware the rule required the initials of the pharmacist and 2 witnesses on each additional page attached for drug destruction. She stated she would see that the failure was corrected. She stated the risk could be a drug diversion. During an interview on 02/23/2023 at 8:10 am the Administrator stated the DON and pharmacist consultant were responsible for medication destructions. She stated she was not aware of the need for Page 1 of 3 676124 676124 02/23/2023 Pinecrest Retirement Community 1302 Tom Temple Dr Lufkin, TX 75904

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many initials on each attached page but expected that the regulation was followed. She stated they had already updated their forms and training had been done to correct the failure. She stated she did not see a risk to the patient or facility. Record review of facility policy dated April 2019, titled, Discarding and Destroying Medications indicated, .2.Non-controlled and Schedule V controlled substances will be disposed of in accordance with state regulations and federal guidelines. 3. Schedule II, III, and IV controlled substances will be disposed of in accordance with state regulations and federal guidelines . Record review of 22 TAC §303.1 Destruction of Dispensed Drugs accessed online 02/22/2023 at https://texreg.sos.state.tx.us/ indicated; (a) Drugs dispensed to patients in health care facilities or institutions. (1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. (A) A written agreement exists between the facility and the consultant pharmacist. (B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: (i) name and address of the facility or institution. (ii) name and pharmacist license number of the consultant pharmacist. (iii) date of drug destruction. (iv) date the prescription was dispensed; (v) unique identification number assigned to the prescription by the pharmacy; (vi) name of dispensing pharmacy; (vii) name, strength, and quantity of drug; (viii) signature of consultant pharmacist destroying drugs; (ix) signature of the witness(es); and (x) method of destruction. C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are 676124 Page 2 of 3 676124 02/23/2023 Pinecrest Retirement Community 1302 Tom Temple Dr Lufkin, TX 75904

F 0755 initialed by the consultant pharmacist and witness(es). Level of Harm - Minimal harm or potential for actual harm v) any two individuals working in the following capacities at the facility: (I) facility administrator; Residents Affected - Many (II) director of nursing; (III) acting director of nursing; or (IV) licensed nurse. 676124 Page 3 of 3