F 0755
Level of Harm - Minimal harm
or potential for actual harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on , interview, and record review, the facility failed to provide pharmaceutical services, including
procedures that assured the accurate accountability of controlled drugs on 4 of 4 medication carts.
Residents Affected - Some
The Change-of-Shift Record of Control Substance Log for the 100/200, 400/500 medication carts were
missing signatures.
These failures could place residents receiving medications in the facility at risk for a drug diversion.
The findings include:
Record Review on 9/6/23 revealed nurses were in serviced on narcotic audit results training, drug
diversion, narcotic Count, and med administration on 6/21/23.
Record review on 9/6/23 of the Control Card Count revealed the sheets were missing signatures on the
following dates and shifts.:
September 2023
Cart 200- 9/2 2 PM - 10 PM on coming and off going shifts signatures missing; 9/6 6 AM - 2 PM on coming
shift signatures missing
Cart 100 - 9/1 10 PM - 6 AM on coming signatures missing.
Cart100/200 9/3 6 Am - 2 PM on coming nurse signature missing and 2 PM - 10 PM on coming and off
going nurse signatures missing.
August 2023
(Documentation provided for 2 carts and the cart number was not designated on either sheet)
8/5 10 PM - 6 AM on coming nurse and 8/6 1 PM to 6 AM off going nurse signature missing.
July 2023
Cart 100
(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:
676365
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
676365
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willow Park Rehabilitation and Care Center
300 Crowne Point Blvd
Willow Park, TX 76087
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 0755
7/1 - 6 AM - 2 Pm on coming and of going nurse signatures2 PM to 10 PM on coming and off going nurse
signatures missing.
Level of Harm - Minimal harm
or potential for actual harm
7/7 - 6 AM 2 PM on coming and off going nurse signature
Residents Affected - Some
7/13 2 pm - 10 PM on coming and off going nurse signatures
Cart 200 7/7 10 PM - 6 AM on coming and 7/8 off going 10 pm - 6 AM nurse signature
During an interview on 9/06/23 at 11:01 AM with LVN A, she stated staff should be signing in and out when
taking possession of the medication cart and be documenting medications in the MAR when they are
signed out of the Narcotic Log. She said it is the responsibility of the charge nurse to monitor the sign in
sheets as well as review they are being completed. She stated nurses were to count drugs at the beginning
and end of their shift with the oncoming nurse, and both shifts should sign the log signifying that they
accepted the count of the narcotics as correct, and they are accepting responsibility for the contents of the
cart. She stated failure to do so could result in a drug diversion.
During an interview with the DON on 9/06/23 at 1:30 PM, she confirmed that the signatures were missing
for the Control Drug Card Count for July 1, 2023. She verified there were missing signatures on the July,
August, and September 2023 control drugs card count sheet. She confirmed she had in serviced all nursing
staff regarding counting and signing the count sheets stating that all narcotics were counted and reconciled
at the beginning and end of each shift by the nurse coming on duty and the off going nurse. She said that
staff should be signing the sign in and out narcotic log (Control Card Count) when they take possession of
the cart. She stated the DON and ADON should be monitoring to see that it is done. She stated failure to
count narcotics, could result in a drug diversion.
Review of facilities Policy titled: Controlled Substance Administration and Accountability (undated) revealed
the following in part: It is the policy of this facility to promote safe, high quality patient care, compliant with
state and federal regulations regarding monitoring the use of controlled substances.
Inventory verification:
Two licensed nurses account for all controlled substances and access keys at the end of each shift. Any
discrepancy in the count must be verified before the end of the shift during which it is discovered.
Resolution can be achieved by review of dispensing and administration records and consulting with all staff
with access. Any discrepancies that cannot be resolved must be reported to the DON immediately. Staff
may not leave the area until discrepancies are resolved.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676365
If continuation sheet
Page 2 of 2
