Health inspection·October 10, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments for 2 of 2 medications. -Medication bubble pack was left unattended on medication cart on Hall 400 -Medication discovered was left on bedside table for Resident #1 These failures could place all residents at risk for obtaining medications that could cause adverse reactions. Findings included: Observation on 10/10/2023 at 9:28am revealed the medication cart in Hall 400 was unattended with a medication bubble pack left on the top of medication cart. Medication was turned over and reflected that the medication pack was full of Lasix medication. The Investigator stood next to medication cart for 5.5 minutes with no staff in sight. There was a resident sitting in a wheelchair next to the medication cart who asked, Is that medication mine? Investigator stated to resident that she was unsure who the medication belonged to. During an interview on 10/10/2023 at 9:33am, LVN A was asked why the medication was left unattended. She stated that she was going to go get the medication. LVN A was asked if any residents wandered down the halls, and LVN A stated yes there was one. LVN walked away from Investigator. Observation on 10/10/2023 at 9:53am revealed Resident #1 was lying in her bed. Observed a cream, Betamethasone Valerate 0.1%, next to the bed. Resident #1 was asked if the medication was hers, she stated that it was, and it was for her eczema and it was ordered for her to apply to herself. Interview on 10/10/2023 at 10:08am with LVN A regarding medication on top of medication cart. LVN A was asked what a negative outcome would be, LVN A stated, Someone could grab it. LVN A was asked about medications left at bedside, LVN stated that if the resident was with it they do not have to be supervised because they will take 1 pill at a time, and they are care planned for that. Record Review of Resident #1's medical chart revealed the following, but not limited to: Resident is an [AGE] year-old female who was admitted to the facility on [DATE] Page 1 of 2 455480 455480 10/10/2023 Heritage Convalescent Center 1009 Clyde St Amarillo, TX 79106

F 0761 DOB: [DATE] Level of Harm - Minimal harm or potential for actual harm Diagnosis: HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE WITH HEART FAILURE AND STAGE 1 THROUGH STAGE 4 CHRONIC KIDNEY DISEASE, OR UNSPECIFIED CHRONIC KIDNEY DISEASE Residents Affected - Some NASAL CONGESTION MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, MULTIPLE SITES TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED MORBID (SEVERE) OBESITY WITH ALVEOLAR HYPOVENTILATION HYPERLIPIDEMIA, UNSPECIFIED OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC) ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS HEART FAILURE, UNSPECIFIED PERIPHERAL VASCULAR DISEASE, UNSPECIFIED CHRONIC KIDNEY DISEASE, STAGE 3B Current Care Plan: completed on 08/24/2023. Minimum Data Set: Her last MDS was completed on 08/08/2023 with a BIMS of 15 and a functionality of total assist. Record Review of Resident #1's medical records revealed the cream that was left next to the resident's bed is Betamethasone Valerate 0.1%, used for eczema and an order was obtained 08/11/2023 and was for 10 days only. The medication had been since discontinued. Interview on 10/10/2023 at 1:35pm with ADON regarding residents that would be self-administering medications. ADON stated that she would have to go through the orders to find out who was. ADON was asked what a negative outcome would be if medications were not locked up. ADON stated that it could lead to an adverse reaction for the resident that got a hold of it. ADON stated that they could eat the med or place it on their skin. No interview with DON, she was not in facility. Record review of facility provided policy titled STORAGE OF MEDICATION, dated 2003 states the following: Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. PROCEDURE 6. Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area. 455480 Page 2 of 2