Health inspection·May 19, 2025

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 all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 of 5 (Resident #1) residents in that: 1. MA failed to ensure medications for Resident #1 were secured when she left Resident #1's medications in a cup on the bedside table unattended. This failure could place residents at risk for harm and result in drug diversion due to medications not being properly secured. Findings included: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had a medical history of chronic diastolic heart failure (a condition where the heart's left ventricle doesn't relax properly between beats, making it difficult to fill with blood), unspecified atrial fibrillation (a heart rhythm disorder where the heart's upper chambers (atria) beat chaotically and irregularly) and chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and fluid from the blood). Record review of Resident #1's admission MDS dated [DATE], Section C- Cognitive patterns revealed Resident #1 had a BIMS score of 15 which indicated she was cognitively intact. Record review of Resident #1's physician orders revealed the following orders with the start date 5/9/2025: Apixaban Oral Tablet 2.5 MG Give 1 tablet by mouth two times a day related to UNSPECIFIED ATRIAL FIBRILLATION Calcium 600mg Carbonate-Vitamin D w/ Minerals Give 1 tablet by mouth two times a day for supplement. dilTIAZem HCl Oral Tablet 30 MG (Diltiazem HCl) Give 1 tablet by mouth two times a day related to HYPERTENSIVE HEART (high pressure in the heart) AND CHRONIC KIDNEY DISEASE Page 1 of 4 676279 676279 05/19/2025 Crown Point Health Suites 6640 Iola Avenue Lubbock, TX 79424

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Docusate Sodium (Colace) Oral Tablet 100 MG (Docusate Sodium) Give 1 tablet by mouth two times a day for Constipation Prevention Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 0.5 tablet by mouth two times a day for 0.5 TAB = 12.5 MG related to HYPERTENSIVE HEART (high pressure in the heart) Multaq Oral Tablet 400 MG (Dronedarone HCl) Give 1 tablet by mouth two times a day related to UNSPECIFIED ATRIAL FIBRILLATION AREDS 2 Oral Capsule (Multiple Vitamins w/ Minerals) Give 1 capsule by mouth two times a day. Tylenol 8 Hour Arthritis Pain Oral Tablet Extended Release 650 MG (Acetaminophen) Give 2 tablet by mouth one time a day for Mild Pain Record review of Resident #1's assessment titled Medication self-administration safety screen revealed; Date: 5/03/2024 Category: May self-administer medications Unsupervised A. Medications .List all medications that are being considered for resident self-administration. List medication, route, dose, and frequency. Indicate where the medication will be stored. Medication#1 1a. Medication name: Symbicort Inhalation Aerosol 160-4.5. Dosage 2 puff. Route: Inhale orally. Frequency by time: At bedside. 1b. Storage: Bedside with resident. Record review of assessment titled Medication self-administration safety screen did not reveal any further medications resident was able to self-administer. During an interview and observation on 5/19/2025 at 10:41AM, Resident # 1 was sitting in her recliner with the bedside table to her left and a nightstand to the right. Resident #1 had a small open medication cup sitting on the bedside table with 6 pills inside. Resident #1 had a small open medication cup sitting on the nightstand table with 3 pills inside. Resident #1 stated the MA had just brought her medication in for her to take. She stated the medication on the bedside table was her regular medication and the cup on her nightstand was Tylenol and Caltrate. Resident #1 stated that is how she takes her medications at home and the MA will bring in her pills and leave them on the bedside table for her to take. She stated sometimes they do watch her take them but not all the time. During an interview with the MA on 5/19/2025 at 11:39AM, she stated she had been working at the facility for the past four years and had been trained on medication administration. She stated she does competencies annually. She stated this morning she had given medication to Resident #1. She stated Resident #1 is here for respite care while Resident #1's family members are away out of town. The MA stated Resident #1's family member had told her she could just prepare the medication and leave it for the resident to take when she was ready. The MA stated sometimes Resident #1 will take it in the morning and sometimes she will wait. The MA stated she did not check to see if Resident #1 had an assessment for self-medication administration. She stated she just went by what the family member had 676279 Page 2 of 4 676279 05/19/2025 Crown Point Health Suites 6640 Iola Avenue Lubbock, TX 79424

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few told her. She stated she does not do that for all the residents, only Resident #1 because that is her home routine. She stated this morning she gave Resident #1 Tylenol, Mutlaq, calcium, metoprolol, Eliquis, Ared and a Colace. She stated she does go back and check to see if Resident #1 had taken her medication. She stated Resident #1 had two cups because she separated the Tylenol and Calcium tablets and the rest, she puts together that way Resident #1 knows what is in each cup. The MA stated the potential negative outcome of leaving medications unattended could be the resident not taking them as ordered. During an interview with the DON on 5/19/2025 at 12:13pm, she stated Resident #1 was here on respite care and the family provided the facility with all her medication. She stated staff had not been trained to allow residents to self-administer their own medication without following the facility policy first. She stated even if family had given those instructions, there should have been a process to ensure safety first. She stated the MA had been trained on medication administration and should not be leaving the pills unattended. She stated the potential negative outcome could be the resident not taking the medication or the medication being accessible to others. She stated if Resident #1 had not wanted to take her medications yet, the medication should have been stored appropriately. The DON stated it was not their policy to leave medication unattended in the resident's rooms. During an interview with the ADM on 5/19/2025 at 12:20pm, she stated staff are expected to follow policy and procedure and not leave medication unattended. She stated there are some instances where residents are able to self-administer but there is a process to follow. She stated family input is wanted but the facility has to assess and determine if it is safe and if the resident is cognitive [NAME] intact. She stated she does not expect staff to take what family says and implement it without following the policy. She stated the potential negative outcome of leaving medication unattended could be the medication not being taken in a timely manner or having the desired effect. During an interview with the MD on 5/19/2025 at 12:29pm, she stated she was okay with Resident #1 taking her medication the same way she does at home. She stated she does expect the staff to monitor the residents when they are taking their medications, but she did not have any concerns with Resident #1 taking her medication unsupervised. Record review of facility document titled Competency Assessment Administering oral medications revealed MA had been checked off on medication administration on 10/30/2024.21. Remain with the resident until all medication have been taken. Record review of facility policy titled Administering Oral Medication dated 2001 revealed: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. .21. Remain with the resident until all medications have been taken. Record review of facility policy titled Medication labeling and storage last revised February 2023 revealed; .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys . I. Medications and biologicals are stored in the packaging, containers, or other dispensing systems 676279 Page 3 of 4 676279 05/19/2025 Crown Point Health Suites 6640 Iola Avenue Lubbock, TX 79424

F 0761 Level of Harm - Minimal harm or potential for actual harm in which they are received . 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Residents Affected - Few 676279 Page 4 of 4