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) Page 1 of 3 675319 675319 05/06/2023 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0761 Ferrous Sulfate Tablet 325 Mg for Anemia (low blood count) Level of Harm - Minimal harm or potential for actual harm Furosemide Tablet 20 Mg for Edema (swelling) Gabapentin Capsule 100 Mg for Osteoarthritis (degenerative joint disease) Residents Affected - Some Plavix Tablet 75 mg for Myocardial Infarction (heart attack) Clopidogrel Bisulfate Tablet 75 Mg for Atherosclerotic Heart Disease (plaque in veins) Losartan Potassium Tablet 50 Mg Essential Hypertension (high BP) Metformin HCI Tablet 500 Mg for Type 2 Diabetes Mybetriq Tablet 50 Mg for urgency of urination. Raloxifene HCI Tablet 60 Mg for Osteoporosis Rosuvastatin Calcium Tablet 10 Mg for Hyperlipidemia (high cholesterol Doxycycline Tablet 6.25 Mg for Infection Metoprolol Tablet 25 Mg for Hypertension (high BP) Rivastigmine Capsule 6 Mg for Alzheimer's Disease Cilostazol Tablet 50 Mg for Atherosclerosis (buildup of fats) Glimepiride Tablet 2 Mg for Type 2 Diabetes Mellitus Hydralazine HCI Tablet 25 Mg for Essential Hypertension (high BP) Hydrochlorothiazide Tablet 12.5 for Essential Hypertension (high BP) 2 Hydrocodone-Acetaminophen Tablet 7.5-325 Mg for Chronic Pain Tylenol with Codeine #3 Tablet 300-30 Mg for pain During an interview on 05/06/2023 at 8:25 AM, the RN-A stated she was the nurse in charge with the cart being hers. RN-A stated the medications in the pill cups were OTC drugs, heart disease medication, BP medications, Diabetes medications, ALZ medications, and Narcotics used for pain. She stated the medications in the pill cups were for the next round of morning medications for her residents. She stated the negative impact to residents were that they could have easily opened the cart and taken the medications without her knowledge, leading to possibility of drug diversion. During an interview on 05/06/2023 at 12:34 PM, the DON stated, the charge nurse should have been monitoring the medication carts on the weekends. She stated the negative impact to residents would be, getting the medications, taking them, which would lead to something more severe such as an overdose or drug diversion. The failure she stated occurred with RN-A, she should not have and knows she 675319 Page 2 of 3 675319 05/06/2023 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0761 Level of Harm - Minimal harm or potential for actual harm cannot preset her medications and she knows as well to lock her cart when it's not in use. The DON stated, RN-A must had wanted to get her medications passed too quickly. Her expectations were for nurses to keep their medication carts locked at all times, and not previously setting up resident medications prior to administering. She stated the nurses should have pulled the medications from their original containers, in front of the resident doorway, locking the cart when stepping away. Residents Affected - Some Record review of facility policy Medication Administration Procedures dated 2003 revealed: . .3. Open the unit dose package only when you are administering medication directly to the resident. Removing the medication from it's unit dose packaging in advance lessens the ability to positively identify the medication and increases the chance of drug administration errors and contamination. .8. After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured. Record review of facility Job Description Charge Nurse from the Human Resources Manual dated 2014 revealed: The following is a non-exhaustive criteria that relates to the job of a Charge Nurse, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for a Charge Nurse and are related to the functions that are essential to the job of a Charge Nurse. Knowledge Base: . Properly administer resident medication. Statement: This position reports to the DON. 675319 Page 3 of 3