Every finding on record at The Heights of Magnolia

Based on observation, record review, and interview, the facility failed to ensure the storage of drugs and biologicals in locked compartments for 2 (hall 500 and 600 carts) of 8 medication carts reviewed for pharmacy services. -Two of the facility's medication carts, hall 500 and 600, were not kept locked or under direct observation of authorized staff in an area where residents could access it. This failure could place residents at risk for accessing and ingesting other residents medications resulting in adverse drug events. The findings included: Observation on 06/10/26 at 1:59 a.m. revealed there were two medication carts located toward the entrance of hall 500 (cart number not located). One medication cart was for hall 500 and the other one was for hall 600. Both medication carts were unlocked, unattended, and not under direct supervision. During an interview on 06/10/26 at 2:06 a.m., Agency Nurse A said it was the first time she had picked up a shift at the facility. She said she was assigned to halls 500 and 600 and their medication carts. She said when she walked away from the medication carts she should have locked them. She said she did not have a reason as to why she left them unlocked. She said an unlocked medication cart could allow any patient or anyone to get anything from an unlocked cart that they should not have access to. During an interview on 06/10/26 at 2:15 p.m., the DON said Agency Nurse A reported to her that she had left her medication carts unlocked during her shift and said the nurse told her she had known better. She said she had started an in-service with the nursing staff over locking their medication carts this morning, 06/10/26. She said Nurse A knew better than to leave her carts unlocked. Record review of the facility's policy, Medication Cart Use & Storage, date revised: January 2023, revealed .The nursing Team Members (Nurses and CMA's) use the medication cart to systematically distribute physician ordered medications to residents.1. SecurityThe medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for each resident for 1 of 6 residents (Resident #49) reviewed for pharmacy services.The facility failed to ensure Resident #49 received Diflucan Oral Tablet daily as prescribed by the physician.This failure could place residents at risk for adverse health conditionsFindings include:Record review of Resident #49's, undated, face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE]. Her diagnoses included reduced mobility, unsteadiness on feet, muscle weakness, dementia (decline affecting memory), lack of coordination (the ability to integrate bodily movements effectively), hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (severe weakness or total paralysis on the left side of the body), and amnesia (loss of memory caused by brain injury).Record review of Resident #49's Quarterly MDS Assessment, dated 02/03/2026, revealed a BIMS score 12 of 15, which indicated mild cognitive impairment and she could understand and respond appropriately to questions. She had no impairment on upper extremity and impairment on both sides on lower extremities.Record review of Resident #49's Care Plan, initiated 04/14/2026, revealed the focus as; at risk for infection or recurrent/chronic infection r/t compromised medical condition: I have an actual UTI infection of yeast in urine. Interventions read, Administer medication and/or antibiotic as per MD orders.Record review of Resident #49's eMAR, dated 04/25/2026, revealed on Diflucan Oral Tablet 200 MG (Fluconazle) Give 1 tablet by mouth one time a day for candiduria for 14 days with a start date of 04/25/2026 and d/c on 04/27/2026. Resident #49 received a check mark for the dates of 04/25/2026 which indicated the medication was administered. Diflucan Oral Tablet 200 MG Give 1 tablet by mouth one time a day for candiduria until 05/10/2026 with a start date of 04/28/2026. The time entry for 04/27/2026 was left blank, which indicated the medication was not documented as received.During an interview and observation on 04/28/2026 at 2:24 PM with MA S, she stated she administered Diflucan Oral Tablet 200 MG (Fluconazle) to Resident #49 on 04/27/2026 and 04/28/2026 during the 7 AM medication pass. This state surveyor showed MA S the eMAR which showed a blank for 04/27/2026 and medication administered on 04/28/2026 and she stated being new to medication pass and she was nervous to answer questions about why the medication was not given or if the medication was given, why it was not documented. This surveyor asked to check MA S medication cart, and she stated she would need to check the cart before it was reviewed by the State Surveyor. This state surveyor proceeded with MA S to check the medication cart, and it was revealed 1 pill popped out from the blister packet of 14 for Diflucan Oral Tablet 200 MG (Fluconazle) was given to Resident #49. MA S stated she did administer Diflucan Oral Tablet 200 MG (Fluconazle) on 04/28/2026 and she only administered medication that was in the cart. This state surveyor did not locate any other medications for Diflucan Oral Tablet 200 MG (Fluconazle) for Resident #49. MA S stated there were no other prescribed medications labeled Diflucan Oral Tablet 200 MG (Fluconazle) for Resident #49 and she checked her cart multiple times a day. MA S stated the risk of medications not being administered according to the order could cause the treatment to not be effective and refused to answer any other questions because she felt she would not know how to respond.During an interview on 04/28/2026 at 2:59 PM with the ADON, she stated the medication for Resident #49 was not administered or charted on 04/27/2026 and she was unsure why. The ADON stated the medication for Resident #49 which pertained to Diflucan Oral Tablet 200 MG (Fluconazle) was prescribed on 04/24/2026 and would have started on 04/25/2026. The ADON stated the medication was received timely by the pharmacy and believed there were multiple orders of the Diflucan Oral Tablet 200 MG (Fluconazle) due to the order being changed and the previous blister packet was destroyed. The expectation for medication pass was the five rights and to wait with the resident while the medication was administered. The ADON stated the risk of the medication not being received could cause a delay in treatment and best practice was to document in the eMAR if the medication was not received and when it was. During an interview and observation on 04/28/2026 at 3:46 pm with the DON, she stated medication was disposed of using destruction bins which were in the mail. She stated the staff were to log the medication and drop them in the bin. This state surveyor and the DON went into the mailroom to check all medications disposed in the last month and none revealed any medications for Resident #49 pertaining to Diflucan Oral Tablet 200 MG (Fluconazle). The DON stated she was unsure why Resident #49 did not receive Diflucan Oral Tablet 200 MG (Fluconazle) prior to 04/28/2026 and stated she verified the order by the physician once it was put into the eMAR. The DON offered to contact the pharmacy to verify if any other blister packs of the medication labeled Diflucan Oral Tablet 200 MG (Fluconazle) were delivered to the facility and the pharmacy confirmed via telephone the blister packet for Diflucan Oral Tablet 200 MG (Fluconazle) was delivered to the facility on [DATE].Record review of the policy for 'Medication Administration' revised date of January 2023 read. Compliance Guidelines:Resident medications are administered in an accurate, safe, timely, and sanitary manner.RESPONSIBLE DISCIPLINESLicensed Nurses, C.M.A.'s2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route.6. Administer medications as ordered by the physician. Routine medications shall be administered according to the established medication administration schedule for the community.10. Record the results of medications administered as necessary.DOCUMENTATION: Initial the electronic administration record after the medication is administered to the resident.