Health inspection·May 6, 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. Based on observations, interviews, and record review, the facility failed to store medications in a locked compartment for 1 of 2 (Medication Cart 1) reviewed for medication storage. The facility failed to keep each resident's drugs in their original containers/packaging. The facility failed to keep medication cart 1 secured when not in use. This failure could result in drug diversion. Findings included: During an observation on 05/06/2023 at 08:20AM, the medication cart #1 was unlocked with the medication cart keys left inserted and hanging from the outside of the narcotic lock. The cart was not in use, with staff not in line of sight of cart with residents present. In the top left drawer, there were 15 separate clear pill cups that included resident morning medications outside of their original containers and placed inside. The loose medications included: Celexa 20 mg tablet for depressive disorder Memantine HCI Tablet 5 mg for Alzheimer's Disease Eliquis Tablet 2.5 mg for Atrial Fibrillation (irregular heartbeat) Cyanocobalamin Tablet 500 Mcg for weakness Gemtesa Tablet 75 mg for overactive bladder Lisinopril Tablet 40 Mg for Hypertension (high blood pressure) Acidophilus/Pectin Capsule for Diarrhea Bentyl Capsule 10 mg for Diarrhea Carvedilol Tablet 12.5 Mg for Hypertension (high blood pressure) Aspirin EC Tablet 81 Mg for Cerebral Infarction (stroke) (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 3 Event ID: 675319 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 675319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444 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)