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. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676307 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Village Healthcare 204 Oak Drive South Lake Jackson, TX 77566 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)