The Department reviewed the facility’s policy for medication destruction. According to policy, if the ED is unable to be present to destroy the medications, a waiver must have been obtained from CCLD. Request for waivers are made to the licensing agency in advance. When non-controlled substance medications are to be destroyed, the medications shall be destroyed in the Community by ED and one other adult who is not a resident. When controlled substance medications are to be destroyed, the medications shall be destroyed in the Community by ED and one other adult who is not a resident.

Interview statement received from staff (S2) indicated when disposing medication there should always be two (2) Med Techs in the room or Med Tech and Nurse. Med Tech is to indicate on destruction records how many medications are being destroyed. Proceed to empty medications in the destruction bin. If Med Tech observe destruction bin is full the facility will notify the company, they use to dispose the medications and empty the bin. Med Techs are not to dispose Narcotics and it’s the Nurse’s responsibility to do so.

Interview statement received from ED indicated, Med Techs and Nurses are assigned to destroy medications, but it’s not assigned to just one individual for the task. ED stated medication destruction has always been done with two (2) people present. Medication destruction are to be destroyed in the medication room or Nurse’s office.

The Department requested for the facility’s approved destruction of medications waiver. LPA Keosavang was unable to locate approved destruction of medication waiver in FAS. ED stated the facility unable to locate the waiver and is unsure if a waiver was submitted to the Department for review. LPA requested for ED to submit destruction of medication waiver to the Department for approval/denial by 03/30/2023.

Continue on LIC 9099-C.

On 12/14/2022, LPA Keosavang toured the assisted living unit medication room with staff (S1). Medication room is located next to dining hall area where residents’ meals are served. LPA observed bio-hazard medication destruction bin to be closed and inaccessible to residents in care. LPA did not observe pungent odor in medication room; however, when destruction bin was opened, LPA observed strong odor. S1 indicated Med Techs at the facility are responsible for medication destruction and that the odor is intolerable. S2 indicated medication destruction does not take place when residents are in the dining room area eating their meals. S2 stated pungent odor does not cause dizziness or nausea. S2 stated Med Techs are wearing masks while destructing medications.

Interview statement received from Director of Health and Wellness (DHW), Alma Gomez, indicated staff designated to destroy medications are to wear gloves for safety and prevention of possible absorption of any medications onto their skin. There is no strong pungent odor that may harm staff and/or residents. For medication destruction it is assigned to Med Techs to destroy medications with another Med tech or Nurse present. Any Narcotics are to be destroyed by Nurse with a Med tech or another management team member present. This can be done either in the Med Room or in the DHW office. All medication destruction needs to be recorded in a Medication Destruction Record sheet with medication name, strength/quantity, date filled, prescription number, disposal date, name of pharmacy and signature of the person destroying medication as well as signature of witness. Any medications that are not narcotics are poured into a medication destruction bin that contains water to dissolve medication. Any Narcotics are poured into a drug buster bottle. The once the bins are full, they are collected by a company designated to collect the bins. Staff designated to destroy medications are to wear gloves for safety and prevention of possible absorption of any medications onto their skin. There is no strong pungent odor that may harm staff and/or residents.

The Department received a total of three (3) interview statements from residents. R1 stated R1 often eats in the dining room area and does not smell any pungent odor coming from medication room. R2 stated R2 has lunch and dinner in the dining room area. R2 denies smelling any pungent odor coming from medication room. R1, R2, and R3 stated the facility is providing a safe environment for residents in care.

Due to the information above, CCL finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Executive Director, copy of report was provided via email.