Inspection·October 16, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 2 (100/200 hall cart) medication carts reviewed for pharmacy services. The facility failed when RN A did not ensure the 100/200 medication carts was locked and medications were secured and not accessible to other staff, residents, or visitors when not in use on 10/16/2024. These failures could place residents at risk of injury and result in residents not receiving doses of medication as well as not being maintained at their best therapeutic level. Findings included: An observation and interview on 10/16/24 at 3:09 PM a medication cart in the 100 hallway was observed unattended against the wall with the drawer's facing outward. The cart was not secured, and the drawers were easily opened revealing various routine medications and other items. Approximately 2-3 minutes later RN A was observed opening the door and coming out of room [ROOM NUMBER] next to where the cart was located against the wall. In an interview with RN A she stated that when leaving the medication cart unattended it is supposed to be locked. She said when not in use and not in direct view of the cart, the laptop on top of the medication cart is to be secured to protect a resident's medical information and the cart is to be locked (by pushing the metal lock in to secure the drawers). RN A stated the cart was used for hall 100 and 200. 4 drawers total were observed unlocked; the first drawer contained items that included insulin and lancets, the second contained routine medications, the third contained items for residents breathing treatments, and the fourth drawer contained items that included urinary drainage bags, gauze packages, and cleaning/sanitizing products. RN A stated that a potential negative outcome to leaving the medication cart unlocked and unattended would be that other residents could have access to the medications and consume something that is not for them. No residents were observed in the hallway at the time of the observations made with the cart left unattended and unsecured. The left-hand side of the cart which contained narcotic medications was observed secured with a different lock. An interview on 10/16/2024 at 03:57 AM DON, she stated that it was her expectation that when the medication cart was not in use that all drawers should be locked and the screen containing resident information on top of the cart should be secured. DON stated that leaving a medication cart unlocked while its unattended could result in a resident ingesting something that they shouldn't. (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: 745051 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 745051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Five Points Nursing & Rehabilitation of College St 3105 Corsair Drive College Station, TX 77845 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)