Health inspection·January 12, 2023

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 in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of two medication carts (Nurse Medication Cart Hall 300) reviewed for medication storage. 1. The facility failed to ensure the Nurse Medication Cart Hall 300 was locked when unattended. 2. The facility failed to ensure LVN A lock Insulin in the medication cart prior to leaving the medication cart unattended. The insulin was left sitting on top of the medication cart. These deficient practices could place residents at risk for loss of prescribed medications, resident's safety and drug diversion. Findings include: Observation on 01/11/2023 at 7:13 AM revealed LVN A parked the nurse medication cart for 300 hall in the hall at room [ROOM NUMBER]. LVN A gathered medications and walked into room [ROOM NUMBER], walked behind a wall to the resident's bedside to administer medications. The medication cart was unlocked and a vial of insulin was sitting on top of the medication cart. Observation on 01/11/2023 at 7:18AM revealed LVN A returned to nurse medication cart 300 hall. The cart was unlocked, and a vial of insulin was left on top. There was one housekeeper in the hall two rooms away there were no residents or visitors in hall. Inventory of nurse medication cart 300 hall accompanied by LVN A at this time: Drawer #1: Insulin vials and insulin injection pens, needles, syringes, heparin (anticoagulant) vials; Drawer #2: Resident individual medications, Liquid medications, locked narcotic box with medications for 8 residents. Drawer #3: Medication supplies; Drawer #4: Nutritional supplements. Page 1 of 2 676307 676307 01/12/2023 Oak Village Healthcare 204 Oak Drive South Lake Jackson, TX 77566

F 0761 Level of Harm - Minimal harm or potential for actual harm In an interview on 01/11/2023 at 7:22AM, LVN A stated she was responsible for making sure the medication cart was locked. LVN A stated she believed it happened because she was not thinking correctly. LVN A stated to make sure it did not occur again she would stop and make sure the cart was locked and no medications were left out on top before leaving. The risk was a resident could take some medications from the cart they should not have. Residents Affected - Few In an interview on 01/11/2023 at 8:54 AM, the DON stated LVN A told her she forgot to lock the cart. The DON stated the nurse working the cart was the one responsible for making sure the cart was locked The risk was anyone could get into the cart. The DON stated she does random checks on medication carts during medication pass checking the medication carts were locked The DON stated the plan to prevent this in the future was to educate. In an interview on 01/11/2023 at 9:09 AM, the Administrator stated she expected the medication cart to be locked and all medications secured when it was left unattended. Record review of the facility's policy, Security of Medication Cart, revised April 2007, read in part Policy Statement: The medication cart shall be secured during medication passes. 1.The nurse must secure the medication cart during the medication pass to prevent unauthorized entry .4. Medication carts must be securely locked at all times when out of the nurse's view 676307 Page 2 of 2