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 that drugs and biologicals were stored
in locked compartments and accessed only by authorized personnel for 1 of 4 residents (Resident #1)
reviewed for medication storage.
Resident #1 had two unidentified pills on his bedside table on 06/17/25 and did not self-administer his own
medications.
This failure could place residents at risk of inadequate therapeutic outcomes or decline in health.
Findings included:
Record review of Resident #1's face sheet dated 6/17/25 revealed a [AGE] year-old male admitted on
[DATE]. His diagnoses included type 2 diabetes (the body has trouble controlling blood sugar and using it
for energy), chronic kidney disease (a disease characterized by progressive damage and loss of function in
the kidneys), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should).
Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIMS score of 8 out of
15 which indicated he was moderately impaired.
In an observation and interview on 06/17/25 at 10:36 a.m. of Resident #1 in his room revealed two
unidentified pills on his bedside table. Resident said that he was not aware of the pills on his left side bed
table. He said they gave him too many pills and maybe one or two fell out when he was taking them.
In an interview and observation on 06/17/25 at 10:36 a.m. the Wound Care nurse said the two pills should
not be left at the resident's bedside. She said that she would take them out of the room. She removed both
pills and put them in her biohazard bag. She stated the resident had been at risk of receiving a double dose
of medication or taking medication without the knowledge of the facility.
In an interview on 06/17/25 at 11:00 a.m., the LVN stated she was the nurse for Resident #1. She said that
she had given the resident pain medication at 09 AM and it was not time for more. She said she always
goes to the right side of his bed and did not see the medication on the left side table. She said if she had
she seen the two pills she would have taken them out of the room. She said the risk of medication at the
bedside was that the resident could get double dosed.
(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:
675018
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
675018
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Oaks Health and Rehabilitation Center
2416 NW 18th St
Fort Worth, TX 76106
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview on 6/17/25 at 1:39 p.m. the acting DON said the expectation was that the nursing follow
protocol to administer medication, watch them take the medication, if the resident refuse, document it and
notify the doctor. She stated she had already started the in-service with the staff regarding administering
medications. The risk to the resident when medication was left in the room would be that the resident could
take the medication and have side effects, and no one would know that he had taken it or what he took. The
person responsible to ensure medication was administered properly would be the nurse administering the
medication.
In an interview on 06/17/25 at 4:09 p.m. the Administrator said she the expectation was to administer the
medication and watch the resident take the medication. If they refused, try again and if the resident refused
again dispose of the medication properly. The risk was a potential side effects and could cause imbalance
or worse sickness. The person responsible to ensure medication was administered properly would be the
person passing medications. She stated they have already started doing in-service with the med aides and
nurses and department heads to ensure they know not to leave medication in the room with a resident.
Record review of the facility's undated Medication Administration policy read in part, .i.e. observes the
resident take the medications
Record review of the facility's Storage of Medication policy undated read in part, Medications and
biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of
the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or
staff members lawfully authorized to administer medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675018
If continuation sheet
Page 2 of 2
