Health inspection·June 7, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 all drugs and biologicals, in accordance with State and Federal laws, were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 3 residents (Resident #2) reviewed for storage of drugs. The facility failed to ensure Resident #2's medications were secured. This failure could place residents at risk of medication misuse and diversion. Findings include: Record review of Resident #2's admission Record, dated 6/4/24, reflected the resident was initially admitted to the facility on [DATE]. Resident #2 had diagnoses which included: Right femur fracture, Muscular Dystrophy (disease that causes weakness and loss of muscle mass), Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), hypotension (low blood pressure), and Dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #2's entry Comprehensive MDS, dated [DATE], reflected the resident had a BIMS score of 13, which indicated her cognition was intact. Record review of Resident #2's Order Summary, dated 6/4/24, reflected the following orders: Acidophilus Oral Tablet, Give 1 tablet mouth one time a day related to UTI; Aspirin Low Tab 81MG EC, Give 1 tablet orally one time a day related to acute embolism; Atorvastatin Tablet 40MG Give 1 tablet by mouth in the evening related to Hyperlipidemia; Cranberry Oral Tablet 250 MG, Give 1 tablet by mouth one time a day related to UTI; Glipizide ER TAB 2.5MG Give 1 tablet by mouth one time a day related to TYPE 2 Diabetes Mellitus; Losartan TAB 25MG Give 1 tablet by mouth one time a day related to Essential hypertension; Myrbetriq Oral Tablet Extended Release 24 Hour 50 MG, Give 1 tablet by mouth one time a day for OAB; Oxybutynin Chloride ER Tablet Extended Release 24 Verbal Hour 10 MG Give 1 tablet by mouth one time a day for Over Active Bladder; Vitamin A Oral Tablet, Give 2400 mcg by mouth one time a day for wound healing; Vitamin C Oral Tablet 1000 MG, Give 1 tablet by mouth one time a day for wound healing give 2 tabs=2000mg; Vitamin D3 Oral Capsule 125 MCG, Give 1 capsule by mouth one time a day for wound healing; Zinc Oral Tablet 50 MG, Give 1 tablet by mouth one time a day for wound healing; Zoloft Oral Tablet 25 MG, Give 1 tablet by mouth one time a day for depression. Page 1 of 2 455618 455618 06/07/2024 Eden Home 631 Lakeview Blvd New Braunfels, TX 78130

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 6/5/24 at 12:06 PM, an unlabeled medication cup with a round white pill and a capsule with red/orange powder was on Resident #2's bedside table, unsecured and unattended. Resident #2 stated the white powder was a medicated powder for her skin folds. Resident #2 said the orange one was for her bladder and the white one was a vitamin. Resident #2 further stated the nurse put them there and said, make sure you take them, she said there were about 8-9 pills in the cup and she had taken the others but was waiting to take the last two. During an interview on 6/7/24 at 11:38 AM, LVN A stated she saw a medication cup with pills on Resident #2's bedside table when she entered her room on 6/5/24 to complete a blood sugar check. LVN A further stated she did not leave medications at Resident #2's bedside, adding she only administered injections and narcotics to residents and the MA administered other medications. An attempted interview on 6/7/24 at 11:58 AM with MA A was unsuccessful. During an interview on 6/7/24 at 1:09 PM, the DON said she expected MAs to watch the residents take their medications before they left the residents' rooms and to their best ability ensure the resident had taken their medications. The DON said her expectation was that medications were not left in resident rooms. The DON said MAs were responsible for ensuring residents took their medications and no medications were left in the rooms. The DON sad the resident could be affected if she did not take medications to treat her conditions. Record review of the facility policy titled, Medication Administration, dated 9/24/13, reflected the following: .Administer all medications to the resident; making sure the resident takes them 455618 Page 2 of 2