F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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 and to permit only authorized personnel to have access for 1 (3rd Floor Treatment
Cart) of 2 Treatment Carts, 2 (340 Hall Nurses Medication Cart and 200 Hall Nurse Medication Cart) of 8
Nurses Medication Carts reviewed for medication storage.
The facility failed to ensure the 3rd floor Treatment Cart was locked when not in use.
RN A and MA B, who shared the 340 Hall Nurses Medication Cart, on the 3rd Floor, failed to ensure it was
locked.
LVN C failed to ensure the 200 Hall Nurse Medication Cart, on the 2nd Floor - Secured Unit, was locked.
These failures could affect residents by placing them at risk of ingestion/exposure to medications not
intended for them and drug diversion.
Findings include:
An observation on 05/29/2024 at 10:49 AM, on the 3rd floor, revealed the Treatment Cart was unlocked and
parked across from the nurse's station and against the wall outside the therapy gym. Staff and residents
were observed passing the cart. The top drawer of the cart revealed Mupirocin ointment (topical cream
used to treat secondarily infected traumatic skin lesions due to specific bacteria and is available only with
your doctor's prescription), Bacitracin ointment (used to prevent minor skin infections caused by small cuts,
scrapes, or burns), and skin, and wound gel. There was no one at the nurse's station.
An observation on 05/29/2024 at 11:37 AM, on the 340 halls revealed a Medication Cart parked against the
wall facing outward to the hall. The lock was open and in the unlocked position. There were no staff in the
hall, but two residents were observed, in wheelchairs, self-ambulating toward the dining room area.
In an interview on 05/29/2024 at 11:40 AM, RN A stated the 340 Hall Nurse Medication Cart belonged to
MA B and should be locked. She said she did not know where MA B was at the time. She said Medication
Carts should always be locked to ensure residents do not get into them and take medications that were not
prescribed to them. She stated all staff on the 3rd floor have access to the treatment cart, so she did not
know who left it unlocked but it should also be secured because it contained
(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:
675757
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
675757
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Signature Pointe
14655 Preston Rd
Dallas, TX 75254
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
treatment ointments that could be harmful if consumed.
Level of Harm - Minimal harm
or potential for actual harm
In an interview on 05/29/2024 at 11:57 AM, MA B stated she had used the 340 Hall Medication cart but
passed it back to RN A about 10:00 AM. She denied leaving it unlocked and said RN A last used the
Medication Cart. She stated all Medication Carts should be locked when not in use to ensure resident
safety. She said anyone could get into the carts and take medications that were not prescribed to them.
Residents Affected - Some
In an interview on 05/29/2024 at 12:05 PM, the ADON stated the medication and treatment carts should
always be locked when not in use to prevent residents from having access to medication that may be
harmful to them. She stated the 340 Hall Medication Cart was the responsibility of RN A, however, MA B
was helping on the floor today and also had access to the cart. She said all nurses had access to the
Treatment Cart on the floor. She stated she expected both Treatment Carts and Medication Carts to be
locked and secured when not in use.
An observation on 05/29/2024 at 12:25 PM, revealed the 200 Hall Treatment Cart, in the secured unit,
parked against the wall facing outward in the dining room. The lock was open in the unlocked position.
Residents were observed in the dining room eating and wandering from table to table near the unlocked
cart. An unidentified staff member sat at the other end of the dining room assisting a resident to eat. No
other staff were observed near the cart.
In an interview on 05/29/2024 at 12:30 PM, LVN C stated he was at the nurse's station and got distracted,
forgetting to lock the 200 Hall Nurse Medication Cart when he left it in the Dining Room. He stated the
Medication Cart should always be locked, especially in the secured unit where residents often wandered
around. He stated they could get into the cart and consume medications not prescribed to them.
In an interview on 05/29/2024 at 12:16 PM, the DON stated staff know the carts should be locked when not
in use. She said they had multiple in-services on the topic.
In an interview on 05/29/2024, the Administrator stated she expected the staff to ensure Medication Carts
and Treatment Carts were locked to ensure resident could not have access to unprescribed medications.
She said it was the DON's responsibility to ensure nursing staff followed this policy.
Record review of the facility's policy titled, Security of Medication Cart, revised April 2007, reflected, Policy
Statement: 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When
the medication cart is not being used, it must be locked and parked at the nurses' station or inside the
medication room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675757
If continuation sheet
Page 2 of 2
