Health inspection·August 4, 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. Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments for one (Med cart 1) of two medication carts reviewed for medication storage. The facility failed to lock Med cart 1 leaving all medications on the cart accessible. These failures could residents by placing them at risk for possible drug diversions. Findings included: Observation of Medication pass on 08/04/23/23 at 10:35 AM of Med aide A passing medication to a resident and leaving the cart unlocked while entering the resident room. Observation on 08/04/23 at 11:33 AM revealed a unlocked med cart on the 600 hall not facing in toward a resident room. All drawers were accessible and able to be pulled open. There was no staff member near the med cart. Med aide A walked out of a resident room and stated it was his cart. Interview on 08/03/23 at 11: 37AM with Med aide A revealed he had worked in the facility for 1 year. Med aide A stated he was aware the med cart should always be locked when he was not present, and the cart should be turned in toward the resident room while passing medication. Med Aide A stated he forgot to lock the cart while entering a resident room. Med Aid A stated he did not usually leave the cart unlocked. Med aide A stated the risk of leaving the cart unlocked and unattended would-be residents or staff would have access to the medication. Interview on 08/03/23 at 12:05PM with the Administrator and DON revealed they were aware of Med aide A leaving the cart unlocked twice while the surveyor was on the floor. The administrator stated the expectation was for Med carts to be always locked when unattended. The Administrator stated Med Aide A had worked in the faciliy for a while and understood that leaving the cart unlocked was not apart of the facility practice. The Administrator stated the Med Aide was immediately removed from the floor and in serviced on med storage. The DON stated she would immediatley in- service remaining nursing staff on the hall. Review of the policy Storage of medication section 4.1 dated 2007, revealed, In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medication( such as medication aides) are allowed to access medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by Page 1 of 2 676453 676453 08/04/2023 Simpson Place 3922 Simpson Street Dallas, TX 75246

F 0761 persons with authorized access. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676453 Page 2 of 2