Health inspection·June 7, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some then RN A did not have a visual of the medication cart and it was not secured. The Pharmacy LVN stated the risk of not locking the medication cart was residents could go inside the cart and take something, if they ingested a medication, it could be fatal, and at least harmful to the resident. The Pharmacy LVN stated RN A was a nurse for several years and knew better than to keep the medication cart unlocked. The Pharmacy LVN stated nurses and medication aides were taught during orientation and during job training on the floor the importance of medication cart security. During an interview on 6/7/23 at 11:02 a.m. with RN A, in Wing A with the Pharmacy LVN present, RN A stated she did not see the State Surveyor open the medication cart top two drawers when the medication cart was unlocked at the nurses station. RN A stated the top right drawer contained bottles of prescription resident medication and the second drawer contained the locked box. RN A stated, I guess I didn't have visual of it. RN A stated the medication cart should be locked at all times when not in use, so residents do not get into the medication. RN A was asked what the risk was of the medication cart being unlocked and RN A stated I don't know what you want me to say. How would I know if I didn't see what they took. The Pharmacy LVN stated, the risk could be harm or death, the resident could have an adverse reaction and we would not know what they took. During an interview on 6/7/23 at 11:15 a.m. with the Pharmacy LVN stated RN A told her she left the medication cart unsecured. The Pharmacy LVN stated RN A knew better than to keep the medication cart unlocked and because she had been the ADON, there was no reason for her not to know that the cart needed to be secured. During an interview on 6/7/23 at 1:40 p.m., RN B stated if RN A was behind the nurses station and could not see the drawers to the medication cart, then RN A did not have visual of the cart, and it was unsecured. RN B stated medication carts were supposed to be locked at all times when the drawers were not in visual. RN B stated the risk of the medication cart being unsecured was a resident could take medications, sharps, thermometers, or supplies that could cause harm. RN B stated if a resident took a medication, the resident could have interactions, allergic reactions and it could cause physical harm to the resident. RN B stated if a resident took sharps or supplies such as scissors, the resident could use those items to harm themselves. RN B stated RN A was an ADON in the facility until recently and had been trained to secure the medication cart at all times. RN B stated if a resident was in a wheelchair in front of the medication cart and RN A was behind the nurses station, there would have been no way she would have seen a resident open a drawer. During on observation and interview on 6/7/23 at 1:55 p.m. in A Wing, Medication Aide C was observed standing on the outside of a partition wall assisting 2 unidentified residents with medications. Upon approach to the hallway on the left, 2 medication carts (#2 and #3) were observed unlocked on the opposite side of the partition wall and a resident walking towards the medication carts. Cart #2 was observed to have an unsecured partially filled medication card of Celecoxib 100mg left on top of the Cart #2. The MA was observed to come from behind the medication partition wall to where the Medication Carts were parked. MA stated she was assigned to both carts and left them unlocked because she was assisting a resident who she thought was sliding out of her wheelchair. MA C stated she also left the medication on top of Cart #1. MA C stated she should lock the carts when she was not using them, and she was trained to keep the medication carts locked. MA C stated after unlocking a medication cart, she was supposed to lock it back up and both carts should not be unlocked. MA C stated, I am sorry, I am human and make mistakes and then MA C started to walk away. The State Surveyor asked MA C if she was going to lock up the Celecoxib medication before leaving the area. MA C grabbed the medication card and locked it inside Cart #2. MA C stated Celecoxib was used for pain, but it was not a controlled substance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675874 If continuation sheet Page 2 of 4 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 675874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/7/23 at approximately 2:30 p.m., the Human Resources Director stated all staff were trained on medication cart security. The Human Resources Director stated she did the orientation with new staff and then when staff were put on the floor they were partnered with a nurse and taught medication security and to keep the medication carts locked at all times. The Human Resources Director stated RN A and the MA were trained on medication cart security and part of their job duties included dispensing and storing medications. During an interview on 6/7/23 at 2:45 p.m., the Pharmacy LVN stated she was informed by the MA C that she left a medication on the cart and left both medication carts unlocked. The Pharmacy LVN stated the MA C told her she thought a resident was falling out of her wheelchair and went to assist the resident. The Pharmacy LVN stated both medication carts should not have been unlocked at the same time nor should medication have been left on top of the cart. The Pharmacy LVN stated having 2 different staff (RN A and MA C) in the same wing (A) leaving medication carts unsecured was a problem and would be addressed. During an interview on 6/7/23 at 3:15 p.m., the ADM stated she was aware RN A and the MA C failed to secure the medication carts by keeping them locked. The ADM stated staff would be in-serviced on locking medication carts and the importance of medication cart security. The ADM stated staff knew medication carts should be locked at all times when not in use to prevent residents, staff, or visitors from taking medications that were not theirs. Record review of the facility provided Charge Nurse job description, dated 7/1/2020, revealed the following: Results Statement: To contribute to the success of the community by providing quality nursing care to residents and to coordinate total nursing care for residents by implementing specific procedures/programs and being in compliance with all (insert facility name) policies and procedures, state regulations and federal regulations. -Order, receive and store medications appropriately. Record review of the facility provided Certified Medication Aide job description, dated 7/1/2020, revealed the following: Results statement: To support the community by ensuring residents are well cared for and receive accurate medications as ordered by the physician/physician extender in accordance with established nursing standards, standards of medication aide practices, state and federal requirements, and guidelines of the community related to medication administration. Record review of the facility's policy titled Medication Cart Use and Storage, dated 3/15/2019, reflected the following: Compliance Guidelines: Security: -The medication cart and its storage bins are kept locked until the specified time of medication administration. -If an emergency occurs during the medication pass, the nurse/mediation aide securely locks the medication cart before attending to the emergency situation. -During routine administration of medications, the cart may be kept in the doorway of the resident's room with: Drawers unlocked and facing inward, and within sight of the nurse. No medications are kept on top of the cart . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675874 If continuation sheet Page 3 of 4 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 675874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720 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)

F 0761 Procedure: Level of Harm - Minimal harm or potential for actual harm -Lock the medication cart. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675874 If continuation sheet Page 4 of 4