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 (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: 455856 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 455856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Van Healthcare 169 S Oak St Van, TX 75790 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)