Inspection·January 14, 2025

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, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and only authorized personnel have access to the keys for 1 (Medication Cart and Medication Cart Keys on RH #1400) of 3 medication carts reviewed for storage of medication. LVN N failed to ensure that medication cart keys and drawers were secured before walking away from the cart on RH #1400. This failure could place residents at risk of overdosing, theft of medication cart keys, and drug diversion. Findings included: In an observation on 01/14/2025 at 1:15 PM, a medication cart was observed unlocked on RH #1000 with the red button extended indicating it was not locked, and the medication cart keys lying on top of the cart. There was not a facility staff with the cart and keys. At 1:18 PM the SSD was observed walking toward the surveyor and medication cart. The surveyor asked who was the authorized staff that was in possession and control of the medication cart and keys. The SSD searched and found out that LVN N was the assigned staff to the medication cart. LVN N was located by SSD in resident room [ROOM NUMBER]. In an interview with LVNN on 01/14/25 at 2:05 PM, she stated she was called to assist a CNA with a blood sugar patient, and this distracted her, and she forget to lock the cart and take the keys. She stated she has never left an unlocked medication cart and keys exposed before. LVN N stated it was important for the medication cart to be locked when unattended and the keys in her possession (in her pocket) to prevent staff, visitors, and residents from accessing resident medications, blood sugar machines, sharp objects, and preventing drug diversions. She said the risk of leaving the medication cart unlocked with the keys on top, could lead to patient's accessing medication, missing keys, and resulting in a negative or adverse reactions causing harm. In an interview with the DON on 01/14/25 at 2:58 PM, revealed it was her expectation that all authorized staff lock the medication cart and keep the keys on them at all times before walking away. The risk of failing to lock the medication cart and secure medication keys, could lead to theft of medication, theft of keys, resident missed medication, uncertified staff, visitors, and residents from having access to the medications and supplies located inside the cart. She stated the potential harm (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455798 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bedford Wellness & Rehabilitation 2001 Forest Ridge Dr Bedford, TX 76021 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)