Health inspection·August 24, 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. Based on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 4 medication carts (100 hall medication cart) reviewed for drug security. 100 Hall nurse's medication cart was left unattended, unlocked with the keys hanging from the lock outside the nurses' station with the drawers facing the outward and could be opened by anyone who passed by. This failure could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects. The findings included: Observations on 08/17/2024 from 5:04 p.m. to 5:10 p.m. during in interview with RN A on 100 hall out of site of the nurses station, RN A stated she was doing wound care on 08/17/24. As the surveyor and RN A walked over to the nurses' station the 100 Hall medication cart was parked outside the nurse's station towards the 100 hall with the keys hanging from the lock that was in the unlocked position, the drawers were facing outward and could be opened by anyone who walked by, and the nurse responsible for the 100 Hall medication cart was not within site of the cart. As RN A walked by the 100 Hall medication cart with the keys in the lock that was in the unlocked position, she removed the keys from the lock, put them in her scrub top pocket, but did not lock the medication cart. RN A and the surveyor walked into the nurses' station where the unlocked drawers to the 100 Hall medication cart were out of their line of site. While the surveyor was interviewing RN A, an unidentified male visitor walked by the unlocked 100 Hall medication cart with the drawers faced outward. RN B, who was working on 100 hall, walked from the direction of the front offices, past the 100 Hall medication cart, reached over to the unlocked cart and the surveyor heard a clicking sound like the lock had been pushed into the cart and RN B walked into the nurses' station and sat down. When the surveyor stepped out of the nurses' station and passed by the 100 Hall medication cart it was locked. In an interview on 08/17/24 at 6:06 p.m. RN B, who was responsible for the 100 Hall medication cart, stated she always would push on the locks on the medications carts when she walks by them to make sure they were locked. RN B said she could not remember if the 100 Hall medication cart had been unlocked when she walked by it when the surveyor was talking to RN A at the nurses' station. In an interview on 08/23/24 at 5:23 p.m., RN A stated she did not remember what she removed from Page 1 of 2 676224 676224 08/24/2024 The Heights on Huebner 10127 Huebner Rd San Antonio, TX 78240

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the medication cart that she and the surveyor passed by on 08/17/24, even after the surveyor asked her if she remembered pulling the keys out from the lock. RN A stated the cart that was parked outside the nurses' station facing the 100 hall on 08/17/24 would have been the 100 Hall nurses' medication cart. In an interview on 08/24/24 from 11:04 a.m. to 11:24 a.m., the DON stated medications were kept secured in a locked medication cart, and the medication cart keys should be always kept on the nurse or medication aide responsible for the cart. The DON stated the harm of having an unlocked medication cart with the drawers accessible to anyone who walked by would be they could take the medications from the cart and ingest the medications. In an interview on 08/24/24 at 11:38 a.m., the Administrator stated medications were kept secured in the locked medication cart and the nurse would keep the medication cart keys with them, not on top of the cart, hanging from the cart. The administrator said if the nurse was out of site of the medication cart the medication cart needs to be locked. The administrator stated the harm that could happen if the medication cart keys were left in an unlocked medication cart with the drawers facing outward could result in a resident could get into the cart, have access to the medications, and take the medications or someone could steal the medications from the cart. Record review of the Medication Cart Use & Storage Policy, dated 03/15/2019, revealed 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/medication aide securely locks the medication cart before attending to the emergency situation .Medication cart keys shall be kept in the nurse's/medication aide's possession until turned over to the next shift nurse. 676224 Page 2 of 2