Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews, and record review the facility failed to ensure that medications were secure and
inaccessible to unauthorized staff and residents for 2 (one medication cart for Hall 100 and one medication
cart for Hall 500) of 5 medication carts and two medication rooms reviewed for medication storage.
The facility failed to ensure medication supplies were all stored in locked compartments and permit only
authorized personnel to have keys, when MA A's one medication cart for Hall 100, was left unlocked an
unattended by MA A.
The facility failed to ensure medication supplies were all stored in locked compartments and permit only
authorized personnel to have keys when MA B's one medication cart for Hall 500 was left unlocked and
unattended by MA B.
The facility failed to ensure medication supplies were all stored in locked compartments and permit only
authorized personnel to have keys when LVN C's one medication cart for Hall 500 and medication room for
Hall 500 were left unlocked and unattended by LVN C.
This failure could result in resident access and ingestion of medications leading to a risk for harm and
possible drug diversion.
Findings included:
An observation on 09/06/23 at 8:54 a.m. revealed MA A's one medication cart on Hall 100 was left in the
hallway outside of the break room. MA A was in a resident's room with her back to the unlocked medication
cart, giving medication to the resident. The lock on the medication carts were popped out showing the red
bottom indicating the carts were unlocked.
An observation on 09/06/23 at 9:22 a.m. revealed MA A's one medication cart was left at the end of Hall
100 near the dining room unlocked. MA A's whereabouts was unknown at this time and no other staff was
in the hallway. An unknown resident rolled past the unlocked medication cart and a visitor walked past the
unlocked medication cart. The lock on the medication carts were popped out showing the red bottom
indicating the carts were unlocked.
An observation on 09/06/23 at 9:37 a.m. revealed MA B's medication cart was left outside of room [ROOM
NUMBER] unlocked. MA B was inside the resident's room, with the door open, giving medication with her
back to the medication cart. Further observation revealed MA B never looked at the cart when
(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 3
Event ID:
675806
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
675806
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurenwood Nursing and Rehabilitation
330 W Camp Wisdom Rd
Duncanville, TX 75116
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 - Some
she was in the resident's room. The lock on the medication cart popped out showing the red bottom
indicating the carts were unlocked.
An observation on 09/06/23 at 9:39 a.m. revealed MA B's medication cart was left outside of room [ROOM
NUMBER] unlocked. MA B was inside the resident's room, with the door open, checking the resident's
blood pressure. MA B opened the unlocked cart and obtained medications for the resident. MA B returned
to the room, giving medication with her back to the medication cart. Further observation revealed MA B
never looked at the cart when she was in the resident's room. The lock on the medication cart popped out
showing the red bottom indicating the carts was unlocked.
An observation on 09/06/23 at 9:44 a.m. revealed MA A's unlocked medication cart for Hall 100 was outside
room [ROOM NUMBER], the privacy curtain was pulled obstructing the ability to see the medication cart.
The medications carts remained unlocked and not in direct site of the MA. The lock on the medication cart
popped out showing the red bottom indicating the cart was unlocked.
In an observation on 09/06/23 at 10:10 a.m. with MA A of the medication cart for Hall 100 revealed: for
Resident #1 Alopurinol 100mg (gout), Duloxetine Slow release 80mg (depression), MiraLAX 17g
(constipation), Plavix 75mg (blood thinner), Carvedilol 12.5 mg (hypertension), Docusate sodium 100 mg
(constipation), Multivitamin-minerals oral tablet (Supplement), Protonix delayed release 40 mg (gastric
reflux), Meclizine 25 mg (dizziness), Pentoxifylline 400 mg (heart disease), Torsemide 20mg (heart failure),
and Vitamin C 1000 mg (supplement).
In an observation on 09/06/23 at 10:20 a.m. with MA A of the medication cart for Hall 100 revealed: for
Resident #2 Macrobid 100mg (antibiotic), Losartan Potassium 100mg (hypertension), Potassium Chloride
extended release 20meq (for potassium imbalance), Hydralazine HCL 25 mg (hypertension), Doxazosin
Mesylate Tablet 4 Mg (hypertension), Docusate sodium 100 mg (constipation), Multivitamin-minerals oral
tablet (Supplement), Calcium-Vitamin D3 Tablet 250-125 Mg (supplement), Citalopram Hydrobromide
Tablet 10 Mg (depression), and Aricept Tablet 10 Mg (dementia).
In an interview on 09/06/23 at 10:30 a.m. with MA A revealed MA A said her medication cart was locked. It
was explained to MA A the drawers on the medications cart were opened, MA A stated, maybe I did not
press the button all the way in. MA A stated if the medications were accessible to the residents, it could
cause them harm and the medications could be stolen.
In an interview on 09/06/23 at 11:00 a.m. with MA B revealed that after the medications were taken off the
cart for the resident it was locked. MA B stated she always had the cart in her sight if it had been left
unlocked. MA B stated she always locked her cart after she was finished with using it. MA B said she was
unaware that her medication cart was left unlocked. MA B stated a resident could take medications and it
could cause harm.
In an observation on 09/06/23 at 11:20 a.m. with MA B of the medication cart for Hall 500 revealed: for
Resident #3 Multivitamin-minerals oral tablet (Supplement), Arginaid (supplement), Ascorbic Acid 500 mg
(supplement) Depakote Sprinkles delayed release 125 mg (seizures), Docusate sodium 100 mg
(constipation), Liquid Protein (supplement), Megestrol Acetate 40mg (appetite stimulant).
In an observation on 09/06/23 at 11:30 a.m. with MA B of the medication cart for Hall 500 revealed: for
Resident #4 Gabapentin Oral Capsule 100 Mg (pain), Donepezil HCl Tablet 10 Mg (dementia), Humalog
KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (diabetes), Budesonide-Formoterol Fumarate
Aerosol 160-4.5 MCG/ACT (Asthma), Pantoprazole Sodium Tablet Delayed Release 40 Mg (heartburn),
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675806
If continuation sheet
Page 2 of 3
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
675806
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurenwood Nursing and Rehabilitation
330 W Camp Wisdom Rd
Duncanville, TX 75116
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 - Some
Morphine Sulfate ER Oral Tablet Extended Release 60 Mg (Pain), Alprazolam ER Tablet Extended Release
24 Hour 0.5 Mg (anxiety), Sennosides Tablet 8.6 Mg (constipation), Enulose Solution 10 GM (constipation),
Amlodipine Besylate Tablet 10 Mg (hypertension), Folic Acid Tablet 1 Mg (supplement), Cozaar Tablet 50
Mg (hypertension), and Finasteride Tablet 5 Mg (urine retention).
An observation and interview on 09/06/23 at 3:30 p.m. revealed an unlocked medication cart was at the
nurse's station on Hall 500. Further observation revealed the medication room had been left unlocked, with
the door open, for Hall 500 nurse's station. LVN C returned to the nurse's station and observed the surveyor
looking at the unlocked medication cart and locked it. LVN C sated she had just forgotten to lock it. LVN C
did not notice that the medication room was unlocked, when it was brought to her attention, she stated, I
had nothing to do with that, and pushed the door closed. LVN C stated she was aware that the medication
cart was always supposed to be locked, when not in use and the same for the medications room. LVN C
stated that it could be dangerous because anyone could enter the cart or the medication room and take
medications and if residents got the medications and took them it could cause them to be harmed. The lock
on the medication cart popped out showing the red bottom indicating the cart was unlocked.
In an interview on 09/06/23 at 3:45 p.m., the DON stated it was her expectation that medication carts
should be locked when not in use. The DON said that the nurses were responsible to keep the medication
carts locked when not in use. She stated if they were not locked, residents and unauthorized staff could get
into the cart and there would be opportunities for harm and medication diversion. The DON said that the
staff that was using the carts were responsible to monitor them to ensure they were locked.
Review of the Policy and Procedure Security of Medication Cart revised dated April 2007, reflected, The
medication cart shall be secured during medication passes and biologicals are stored properly . policy
Interpretation and Implementation: 1. The nurses must secure the medication during the medication pass to
prevent unauthorized entry .3.the medication cart must be locked before the nurse enters the resident's
room [ROOM NUMBER]. The medication cart 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 .
Review of the Policy and Procedure Storage of medications dated December 2020, reflected, The facility
shall store all store all drugs and biologicals in a safe, secure, and orderly manner . 7. Compartments
(including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes). containing drugs
and biologicals shall be locked at all times .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675806
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F761 - Labeling of Drugs and Biologicals
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.
FAQ · About this visit
Common questions about this visit
What happened during the September 6, 2023 survey of THE LAURENWOOD NURSING AND REHABILITATION?
This was a inspection survey of THE LAURENWOOD NURSING AND REHABILITATION on September 6, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE LAURENWOOD NURSING AND REHABILITATION on September 6, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.