Health inspection·September 13, 2023

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 permitted only authorized personnel to have access to the keys for 1 of 2 rooms (medication room and DON office) used for storage of medications and other biological chemicals. The facility failed to ensure the DON's office located on Hall D was secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk for medication misuse, medication diversion, and injury related to ingestion or use of biological chemicals. Findings included: During an observation on 09/12/2023 at 12:05 PM, the following items were noted on open shelves on a wall in the DON's office: 16 bottles (100 tablets each) of Vitamin D3 25 mcg, 1 bottle (100 tablets) [NAME] 500mg Extra Strength Aspirin, 1 unopened box containing 300 cough suppressant lozenges, 1 bottle (16 oz) Dakins Solution (wound cleaner containing sodium hydrochloride), 1 bottle (12oz) Hydrogen Peroxide, 16 bottles (32oz size) hand sanitizer refill solution, 1 partially used plastic container of Drug Disposal (for disposing of drugs), and 10 tubes A&D ointment, and 1 bottle (24 oz) Acaricid (surface disinfectant cleaner). The door to the DON's office was open and nobody was in the office. During an observation on 09/13/2023 at 09:40 AM, the door to the DON's office was noted open and Page 1 of 2 455856 455856 09/13/2023 Van Healthcare 169 S Oak St Van, TX 75790

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nobody was in the office. The same items were noted on the open shelves. There were 2 residents in wheelchairs on the hall. During an interview with the DON at 1:40 PM on 09/13/2023, the DON said the items on the shelves had probably been there since he came in March, 2023. He said he had planned to take the shelves down. The DON stated these items were accessible to residents and should be in a secure location and not available to unauthorized persons. Record review of the facility's undated policy titled Storage of Medications indicated the facility's purpose was to ensure that medications are stored in a safe, secure, and orderly manner. 6. Compartments containing medications are locked when not in use. 455856 Page 2 of 2