Health inspection·April 25, 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 observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for Resident #1 (one of eleven residents) as evidenced by: -Resident #1 had pills in a plastic cup in her right hand and was unattended. This deficient practice could place residents at risk for harm and place the facility at risk for a possible drug diversion. The findings include: Record review of Resident #1's clinical record revealed an [AGE] year-old female admitted to the facility on [DATE] including diagnoses: Alzheimer's disease (a brain disorder that gets worse over time), Rheumatoid Arthritis (is an autoimmune disorder where the immune system mistakenly attacks the joints, causing inflammation, pain, and potential joint damage). Record review of the Minimum Data Set (MDS) dated [DATE] for Resident #1 with a BIMS score 10 (moderate cognitive impairment). Observation and interview on 4/24/24 at 10:45 a.m. revealed in Resident #1's hand a plastic cup with 5 tablets: one large white tablet, 2 medium white tablets, one oblong gray tablet, one small yellow tablet. She stated she fell asleep before she took her medications. LVN #1 observed resident with cup of pills in right hand. LVN#1 stated the resident should not have pills in her room unattended. Interview on 4/24/24 at 10:45 a.m. LVN #1, she stated it is not acceptable for medication to be in resident room unattended. She stated she observed 5 pills in a plastic cup in the residents' right hand. She stated residents should take medication when staff administers medications. This prevents any type of under medicating, over medicating and drug diversion. Interview on 4/24/24 at 11:05 a.m. with the Administrator, she stated residents are not to have medications in their room without a doctor's order, and when licensed staff administer medicine they should assure that the resident takes the medicine that they administer. She states her expectation for medication administration is the medicine makes it into the residence body in the appropriate manner that it is ordered. She states the risk of residents having medication without being observed is- it could cause adverse health reaction or taken by that resident and cause them harm. Page 1 of 2 676081 676081 04/25/2024 East View Healthcare 15880 Wallisville Road Houston, TX 77049

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 4/24/24 at 11:12 a.m. with Medication Aide (MA), she stated she placed resident's medications on the bedside table, administered eye drops, and as she was leaving she saw Resident #1 drinking water and assumed the resident had taken the pills that were on the bedside table. She stated should have verified the medication was taken prior to leaving the room. She stated the risk of leaving medication in a residents room unattended is stockpiling meds, under medicating, other resident could take medication not ordered for them and cause harm to them. Interview on 4/24/24 at 11:24 a.m. with the Director of Nurse (DON), she stated it is not appropriate to leave medications in residents' room unattended. Resident may be under medicated, over medicated, other resident may get incorrect medication and cause harm to themselves. Her expectations for medication administration is that resident will get medications timely, and medications will be observed being taken by staff who give medication, no pills left at bedside. Interview on 4/24/24 at 11:45 a.m. with RN #1, she stated it is important to observe residents take medications at the time being administered to assure a resident is taking the medication., Her expectation is medication aides will stay until medication is swallowed, perform mouth check to assure medicine is not in their mouth . She stated the risk of a resident not taking medications is under medication, overmedicating, and potentially another resident taking incorrect meds. She stated no medication should be left at bedside unattended. Record review of the facility policy titled Administering Medications, 2001 MED-PASS, Inc. revised April 2010. Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. 676081 Page 2 of 2