Health inspection·June 15, 2024

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 observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 3 (Resident #1) residents reviewed for pharmacy services. 1. The facility failed to ensure Resident #1's medications (1 box of 20, 600mg Mucinex tablets and 1 single 10mg Baclofen tablet) were stored and locked in an area not accessible to other staff, residents, or visitors. 2. The facility failed to dispose of medication properly- 1 loose pill (Docusate sodium 50 mg tablet) was found in the private dining room trash can. These failures could place residents at risk of injury and result in residents not receiving doses of medication as well as not being maintained at their best therapeutic level. Findings included: Record review of Resident #1's face sheet dated 06/24/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of multiple sclerosis (a disease where the immune system attacks the protective layer around nerve fibers causing inflammation and lesions), type 2 diabetes mellitus (a condition resulting from insufficient production of insulin causing high blood sugar) with unspecified complications, gout (a type of arthritis that causes inflammation of joints due to excess uric acid)- unspecified, generalized muscle weakness, and hypokalemia (low levels of potassium in the blood serum). Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIMS score of 13 suggesting cognition intact. Record review of Resident #1's care plan revised 05/11/22 revealed focus: The resident has an alteration of musculoskeletal status related to dx : Multiple Sclerosis with interventions of administer medications as ordered. See MAR for current medications and administration orders. Page 1 of 3 675887 675887 06/15/2024 St. Joseph Manor 2333 Manor Dr Bryan, TX 77802

F 0761 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's clinical physician orders revealed an order start date of 01/13/24 for Baclofen Oral Tablet 20 MG (Baclofen)- give 1 tablet by mouth two times a day related to Multiple Sclerosis. Another physician's order with a start date of 03/22/24 revealed Mucinex Maximum Strength Oral Tablet Extended Release 12-hour 1200 MG (Guaifenesin)- give 1 tablet by mouth two times a day for cough do not crush. Residents Affected - Few During an observation and interview on 06/15/24 at 11:28 AM, MA A was observed getting ready to dispense medication outside of Resident #1's room for Resident #1. MA A pulled out a box of Mucinex containing a blister pack of 20, 600mg extended release bi-layer tablets and 1 separate Baclofen 10mg tablet. MA A stated she needed to return to the medication room because she needed an additional Baclofen 10mg tablet to complete the 20mg ordered for Resident #1 that she did not have in the medication cart. MA A was observed leaving the box containing the 20 Mucinex tablets and the single Baclofen tablet on top of the medication cart unsecured and unsupervised as she walked down the hall to the medication room. MA A returned to the medication cart after approximately 4-5 minutes. No residents were observed in the hall during this time. Upon her return, MA A stated she was not supposed to leave medication unattended because someone else could have taken the medication. During an observation on 06/15/24 at 11:36 AM in the special dining room located next to the main dining area a small orange tablet later identified as Senna S docusate sodium 50mg was observed in the trash can. During an observation and interview on 06/15/24 at 11:52 AM with the DON she stated she knew the medication found in the special dining room was Senna a stool softener. It was unknown who the medication belonged to because there was more than one resident on the medication. The DON stated that she remembered LVN B had approached her about it earlier that morning to let her know she found it on the ground in the hall. The DON stated that it was her expectation that non-narcotic medications were disposed of appropriately in a sharps container and should never be disposed of in the trash can. The DON said that medications should also never be left unattended and if leaving the medication cart all medication should be placed in the cart and locked. The DON said that a negative outcome to leaving medication unattended/ unsecured or failing to dispose of it properly could lead to a resident taking a medication which could result in anaphylaxis or other dangerous consequences. During an interview on 06/15/24 at 01:01 PM with Resident #1 she stated she was knowledgeable on the medications she was prescribed and to her knowledge she had not missed any medications and always gets them on time. Resident #1 verified that she does take Mucinex and Baclofen. During an interview on 06/15/24 at 01:26 PM with LVN B she stated she did not recall finding any medication out in the hall or disposing of medication in the trash can. LVN B stated that to her knowledge medications should be disposed of in a kit located in the medication room unless it is a narcotic which requires 2 nurses to sign off on discarding it. LVN B said a potential negative outcome to throwing medication in the trash could result in a resident taking a medication that was not theirs. During an interview on 06/15/24 at 03:00 PM with the ADM, he stated it was his expectation that medications should be locked in a medication cart or in attendance by staff. The ADM said a potential negative outcome would be a resident taking medication that was not theirs. He said the facility does not want any residents getting medications from anyone other than a licensed nurse or provider who was authorized to dispense it. The ADM said medications should be disposed of in a secured container or staff should take it to the DON so she can dispose of it. He stated failing to dispose of it 675887 Page 2 of 3 675887 06/15/2024 St. Joseph Manor 2333 Manor Dr Bryan, TX 77802

F 0761 properly could lead to an unpleasant event. Level of Harm - Minimal harm or potential for actual harm Review of the facility Preparation for Medication Administration policy dated 01/23 revealed: Residents Affected - Few The nursing care center maintains equipment and supplies necessary for the storage, preparation, and administration of medication to residents. The following equipment and supplies are acquired and maintained by the nursing care center for the proper storage, preparation, and administration of medications: Lockable medication carts, medication cabinets, drawers, or rooms with well-lit dose preparation areas. Sharps container readily accessible on or near the medication cart. The nurse or authorized staff member is notified if supplies are inadequate, or equipment fails to work properly. The nurse reports equipment and supply deficiencies to the director of nursing. Additional policies regarding secure storage and disposal of medications were requested from the DON 06/15/24 at 03:00 PM and were not provided by time of exit. 675887 Page 3 of 3