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.
Based on observation, interview, and record review, the facility failed to ensure that all drugs and
biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and
residents for 1 (Treatment cart #1) of 5 medication/treatment carts reviewed for medication storage in that:
Treatment cart # 1 was left unattended and unlocked.
This failure could allow residents, unsupervised access to prescription and over-the-counter medications.
The findings included:
Observation on 12/13/23 at 11:43 AM revealed Treatment cart #1 was left in the facility's C-hall unlocked
and unattended. Upon visual inspection, Treatment cart #1 was observed near the wall with the drawers
facing the hallway, the cart had two empty medication blister packs and what appeared to be a personal
mobile device on the top. Treatment cart #1's drawers were able to be opened and were observed to
contain medications, treatment supplies and treatment scissors. Three staff members and four residents
passed treatment cart #1. At 11:46 AM, LVN A exited a nearby resident room, returned to treatment cart #1,
secured the cart and pushed it towards the nurse's station.
In an interview on 12/13/23 at 11:47 AM, LVN A stated she was assigned to treatment cart #1 and she was
not aware the cart was unsecured while she was in a resident's room. LVN A stated she was asked by
another staff member to assist with incontinent care and left the cart unlocked. LVN A stated she was
trained to lock any medication or treatment cart when not in use. LVN A stated treatment cart #1 contain
medications for g-tubes, breathing treatments, over the counter medications and wound treatment supplies.
LVN A stated if treatment or medication carts were left unlocked, residents could get into the cart and take
medications.
In an interview on 12/13/23 at 2:31 PM, the DON stated LVN A reported the unsecured treatment cart to
her prior to her interview with the surveyor. The DON stated it was expected for nursing staff to secure all
medication and treatment carts when not in use. The DON stated the security of carts would be the
responsibility of all nursing staff but started with the nurse assigned to the cart. The DON stated unlocked
and unattended medication and treatment carts could lead to drug diversions. The DON stated she would
begin to in-service staff on cart security and medication storage.
In an interview on 12/13/23 at 3:41 PM, the Administrator stated the DON notified her about the
(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:
676080
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
676080
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/13/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Town Hall Estates Arlington, Inc.
824 W Mayfield Rd
Arlington, TX 76015
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
unlocked treatment cart prior to her interview with the surveyor. The Administrator stated medication and
treatment carts should be secured at all times. The Administrator stated drugs could go missing if carts
were not secured. The Administrator stated it was the responsibility of all nursing staff to ensure carts were
secured at all times. The Administrator stated staff would be in-serviced on medication storage and security
and carts would be checked at random to ensure they are secured at all times.
Residents Affected - Few
Record review of the facility's policy entitled Security of Medication Cart, revised in April 2007, read in part:
Policy Statement: The medication cart shall be secured during medication passes. Policy Interpretation and
Implementation 1. The nurse must secure the medication cart during the medication pass to prevent
unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during
the medication pass. The cart doors and drawers should be facing the resident's room. 3. When it is not
possible to park the cart in the doorway, the cart should be parked in the hallway against the wall with doors
and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4.
Medication carts must be securely locked at all times when out of the nurse's view .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676080
If continuation sheet
Page 2 of 2
