Unsecured Medication Storage in Nurse's Station
Summary
The facility failed to store all drugs and biologicals in locked compartments, as observed during a survey on Unit 2 East. Specifically, 16 medications for seven residents were found unattended and unsecured on a shelf in the nurse's station, which lacked a door or means to lock the area. The medications included Chlorhexidine mouth rinse, Lactulose, Sorbitol, Ipratropium Bromide and Albuterol Sulfate inhalation, Citrucel Powder, Lanta liquid, Refresh tears, and Betadine solution. These medications were accessible to residents, as the nurse's station was located near a common area where residents were present, and there was no staff within visual view to monitor the area. Interviews with various nursing staff revealed a lack of awareness and adherence to the facility's medication storage policy. Licensed Practical Nurse #2 acknowledged the medications should not have been stored on the shelf and were unsure how long they had been there. Unit Manager Licensed Practical Nurse #4 and Licensed Practical Nurse #5 were unaware that overflow medications could not be stored on the shelf, and both confirmed that the nurse's station was not a secure location. Licensed Practical Nurse #3 noticed the medications but did not take action to secure them or inform the Nursing Supervisor. The Director of Nursing and the Pharmacy Consultant both confirmed that medications should be stored in a locked, secure area, and the nurse's station shelf was not appropriate for medication storage. The Pharmacy Consultant noted that storing medications on the shelf could potentially allow resident access, posing a safety issue. The facility's process for receiving medications involved the Nursing Supervisor delivering them to the appropriate unit, expecting staff nurses to secure them in a medication cart or locked cabinet, which was not followed in this instance.
Plan Of Correction
Plan of Correction: Approved February 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F761- Label/store Drugs and Biologicals** 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? a. For Resident number 94 the eye drops were removed and ordered directly through pharmacy with patient label. b. For Resident number 267 the [MEDICATION NAME] was discarded. c. For Residents 17, 22, 68, 70, 72 immediately removed the medications from the unsecure shelf and placed all their medications in their locked med cabinet and or med cart. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. a. All residents who receive medication and or biologicals have the potential to be affected by this deficient practice. b. On (MONTH) 9, 2025 the DON, ADON and Manager of the unit did a complete med audit. This included all shelves in the center of the unit near common areas where residents sit and no medications were found. An audit was also completed on all medication orders as they relate to supplies on hand. (01) 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur. a. Three (3) cabinets on 2 east were identified to use for stock meds and overflow meds. Maintenance installed locks and all stock and overflow medications are now in the 3 locked cabinets located in the common area above the sink off the nurse’s station. The cabinets are located high on a wall that is in the common area to residents and staff and open to the nurse’s station; the cabinets will remain locked at all times. They are against the wall above the sink. The cabinets are sufficient to hold any overflow medications which do not fit in the locked medication cart and also for stock meds. No narcotics are stored in this area. The narcotics are kept in a double locked cabinet in the nurses stations. There is no overflow area necessary for narcotics. Nursing staff will unlock and obtain overflow medication/biologicals or stock meds as needed per specific orders for patients, lock the cabinet and bring the medication/biological directly to the respective medication cart to be administered and secured and stored. All RN’s, LPN’s will be in serviced by our ADON or nurse managers on all aspects of medication administration & storage, including proper receiving of medications and biologicals from pharmacy and the immediate delivery of the medications and biologicals to the appropriate secured storage area. All RN’s and LPN’s will have the P&P reviewed regarding Medication Cart audits, Medication room audits or medication cabinet audit, medication administration & documentation, storage of medication, and ordering and receiving medications from the dispensing pharmacy. (02) 4. How the corrective action will be monitored to ensure the deficient practice will not reoccur a. Our nurse manager or designee will be completing weekly audits in the common area and nurse’s station to ensure no medications are in an unlocked area. The manager will also conduct weekly medication cart and storage cabinet audits to ensure there are no discontinued medications. Medication administration audits will also be conducted yearly with each RN and LPN’s evaluations to ensure adherence to policy & procedure. (03) b. The nurse manager and or designee is responsible for conducting medication cart audits, medication room audits, medication storage audits, and audits of any medication storage cabinet and refrigerator storage of medications weekly on all Nursing units within TMR. Any negative findings will be addressed and corrected immediately. The results of these audits are given to quality and to the DON who also reports on them at our Quarterly Quality and Resident Safety Committee for review. (04) c. Any negative findings will be addressed and corrected immediately. The results of these audits will be reported by the DON at our Quarterly Quality and Resident Safety Committee for review. d. The pharmacy consultant agreed with the decision for the new location for stock and overflow meds and the security of medications. The pharmacy consultant will audit med storage areas every 2 weeks until we achieve 100% compliance for 8 consecutive audits. Thereafter, the pharmacy consultant will conduct spot audits and a full audit of med carts and med storage yearly throughout the building. (05) e. The Audits done by the nurse manager and or designee will be done weekly until we achieve 100% compliance over 8 consecutive weeks, after which, the findings will be reviewed by the Quality Assurance Committee for compliance. The Quality Committee will provide us with a schedule to follow for future medication cart and storage cabinet audits throughout the year. Medication administration audits will continue to be conducted yearly with each RN and LPN’s evaluations. The results of these audits will be given to the Quality Department and to the DON who also reports on them at our Quarterly Quality and Resident Safety Committee for review. f. While the primary responsibility for audits will be the unit manager, weekly audits may be done by a designee. The designee may include the DON, ADON, the Quality Team, other unit manager and or supervisor. The manager of each unit will be responsible for the delegation each week depending on staff schedules. 5. The date of the correction and the title of the person responsible for the correction of the deficiency. Date of Correction: (MONTH) 5, 2025 Person Responsible: Director of Nursing
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Medication labeling and storage deficiencies were observed during med pass and cart/room checks. An LPN prepared hydrocodone-acetaminophen for a resident from blister packs whose labels did not match the EMR orders, another cart contained a loose pill in an unlabeled state, and a rehab unit med room had a controlled-medication lock box that was not affixed to the refrigerator. The DON and Administrator stated labels should match orders, carts should not contain loose pills, and controlled meds should be securely locked.
Unattended RT Medication Cart Left Unlocked: RT Medication/Treatment Cart A was observed unlocked and unattended in the 200 Hall with the keys hanging from the opened lock while no staff or residents were within eyesight. RT F stated she had stepped away briefly to check on a resident and acknowledged she should have locked the cart. Medications and supplies were visible in the cart, and RT F said she did not know when she was last trained on keeping the cart locked when unattended. The DON and ADM stated staff were expected to keep carts locked when not with them.
Unlabeled medication cups and supplies were left unattended at the bedside of two residents. A CNA stated cream was left in one resident’s room and later applied, while another resident had a clear cup with a spoon and cream on the nightstand. Staff confirmed neither resident had an order to self-administer medications, and an LPN and the DON stated the residents did not have self-administration orders. The facility policy required medications and biologicals to be stored in locked compartments.
Medications in two med carts and one med room were found without opened-on dates, including eyedrops, creams, gels, ointments, and an insulin pen. RN-A and RN-B stated these items should be dated when opened, and the DON confirmed staff were expected to affix and complete date-opened stickers for these medications. Facility policy required containers or vials to be dated when the original seal was broken.
Missing Medication Refrigerator Temperature Monitoring: The facility failed to monitor temperatures in 3 of 3 medication refrigerators. Temperature logs for Station 1, Station 2, and Station 3 showed multiple missing daily entries, and the Administrator confirmed staff were expected to check the refrigerators daily but there was no back-up temperature monitoring system on the days with blank temperatures.
Expired and discontinued medications were left available in multiple medication carts, including Pantoprazole, ABH Gel syringes, and Propranolol. The DON, an LPN, and a medication aide stated the medications should have been removed from the carts and placed in the return-to-pharmacy bin, but they remained on the 100-hall cart and both 200-hall carts.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled in accordance with accepted professional principles. During a medication pass observation, an LVN prepared to give Resident #51 hydrocodone-acetaminophen from the 700/800 hall nurse cart using a blister pack labeled Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth every 6 hours as needed, while the EMR order for that medication was Hydrocodone-Acetaminophen 10-300 mg, give 1 tablet by mouth every 6 hours as needed. The LVN stated the EMR order did not match the blister pack label and that the order would need to be clarified with the prescriber. A second medication pass observation showed another LVN preparing to administer hydrocodone-acetaminophen from the 800 hall medication aide cart to Resident #51 from a blister pack labeled Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth every 6 hours as needed, while the EMR order for that medication was Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth twice daily. The LVN stated the PRN-labeled blister pack should not have been in the medication aide cart and that the cart should have contained a blister pack with routine dosing for the resident. The DON stated the prescription labels on blister packs needed to match the EMR orders and that staff were expected to follow physician orders and clarify orders when needed. On another observation, a loose pill was found in the third drawer of the 500/600 hall nurse cart, and RN B stated loose pills should not be in medication carts because they are unlabeled and could be taken or consumed without knowing what they are. In the rehabilitation unit medication room, the lock box for controlled medications was observed not affixed to the refrigerator. RN G stated the box should be affixed so it could not be removed, and the DON and Administrator both stated lock boxes for controlled medications should be affixed to the refrigerator. Resident #51 had diagnoses including depression, anxiety, seizures, and diabetic neuropathy, with a BIMS score of 14 and opioid use documented in the MDS.
Unattended RT Medication Cart Left Unlocked
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles for 1 of 2 RT carts reviewed. During an observation on 06/11/26 at 8:44 AM, RT Medication/Treatment Cart A was seen in the 200 Hall unlocked and unattended, with the keys hanging from the opened lock. No staff or residents were within eyesight of the cart at that time. During an observation and interview at 8:46 AM, RT F stated she had gone into a resident's room quickly to see what he needed and acknowledged she should have locked her cart when she stepped away from it. RT F opened the top drawer, and medications and supplies were observed in the cart. RT F stated she did not know when she was last trained to keep her cart locked when unattended and did not know of a potential negative outcome to residents. The DON and ADM later stated they expected staff to keep carts locked when not with them and that keys should be kept in their pocket or on their person. The facility policy stated medication carts and supplies are to be locked or attended by authorized persons.
Unlabeled Medications Left at Bedside
Penalty
Summary
The facility failed to follow standards for medication storage for 2 of 6 halls reviewed for unattended medication. During observation, a clear medication cup containing cream was found at the bedside of Resident #86, and the cup was not labeled. Two normal saline flush syringes were also observed on top of the resident’s nightstand. In interviews, the resident’s representative stated staff came in and applied the cream when they changed the resident, and a CNA stated the wound care nurse gave her the cream that morning, she left it in the resident’s room, and later applied it. An LPN stated she was not aware of any cream or normal saline flushes and had not done any of it. A similar observation was made at the bedside of Resident #38, where a clear medication cup with a spoon and cream was left on the nightstand. The resident stated staff apply the cream when they change him. A CNA confirmed the cup with the spoon was at the bedside and said it was cream to apply when the resident was changed, but it should not have been left there. An LPN stated the resident did not have an order to self-administer medication, and the DON later stated that Residents #86 and #38 did not have orders to self-administer medications. The facility policy titled Medication Labeling and Storage stated that medications and biologicals are stored in locked compartments under proper controls and only authorized personnel have access to keys.
Medications Missing Opened-On Dates
Penalty
Summary
The facility failed to ensure medications were appropriately labeled with an opened-on date in 2 of 2 medication carts and 1 of 1 medication rooms reviewed for medication labeling and storage. During observation and interview, the North medication cart contained multiple medications without opened-on dates, including Nizoral shampoo, Victosa insulin pen, Diclofenec Sod Top Gel, Biofreeze gel 4%, Hydrocortison cream 1%, Nystatin cream, Hemorrhoidal ointment, Calmoseptine ointment, Diclofenca Sod Top Gel 1%, and Triamcinolone Acetonide Cream. RN-A stated that all eyedrops, creams, gels, and similar medications in tubes should be dated as soon as they are opened, and that nurses and TMAs should check for an opened-on date when using these medications. The medication room also contained opened medications without opened-on dates, including Sustane eye drops, Ketoconazole cream 2%, Bacitracin ointment, Hydrocortisone cream 2.5%, and Dorzolamide Hydrochloride and Timolol Maleate Ophthalmic Solution 2%. In the East wing medication cart, Hydrocortisone Cream 1% and Diclofenac Sodium Gel 1% were also missing opened-on dates. RN-B stated that if a medication was missing the opened-on date it should not be used because it could be expired and the resident would not get the actual prescribed dose. The DON stated all medications should have an opened-on date clearly affixed and that staff should place an opened-on sticker and fill it out each time a new bottle of eyedrops, creams, gels, or similar medications was opened. Facility policy stated that when the original seal is broken, the container or vial will be dated and the nurse shall place a date-opened sticker and enter the date opened and new expiration date.
Missing Medication Refrigerator Temperature Monitoring
Penalty
Summary
The facility failed to monitor temperatures in 3 of 3 medication refrigerators. A review of the temperature logs for Station 1, Station 2, and Station 3 for 5/2026 showed multiple missing daily temperature entries, including 10 missing days for Station 1, 9 missing days for Station 2, and 12 missing days for Station 3. On 6/4/26, the Regional Director of Clinical Operations provided the logs, and on 6/5/2026 the Administrator stated staff were expected to check the medication refrigerators daily and confirmed the missing temperatures. The Administrator also stated the facility did not have a back-up temperature monitoring system on the days with blank temperatures.
Expired and Discontinued Medications Left in Medication Carts
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted storage and labeling practices because expired and discontinued medications were left in medication carts. During an observation with the DON, the 200-hall upper medication cart contained a Pantoprazole 40 mg medication card with 27 pills remaining and a pharmacy expiration date of 5/31/26, even though the physician’s order had been discontinued on 3/9/26. The expired Pantoprazole remained available for use in the cart. Nurse #1 stated the medication had been overlooked and should have been removed from the cart and placed in the return-to-pharmacy bin in the medication room when the order was discontinued. Additional observations showed similar issues on other carts. The 100-hall medication cart contained a bag of ABH Gel syringes with 15 syringes remaining and a pharmacy expiration date of 6/1/26, although the physician’s order had been discontinued on 6/1/26. The 200-hall lower medication cart contained Propranolol 20 mg tablets with 25 pills remaining and a pharmacy expiration date of 11/30/25, although the order had been discontinued on 7/15/25. Staff interviews indicated that nurses and medication aides were expected to check expiration dates before administration, and that discontinued or expired medications should be removed from the carts and placed in the return-to-pharmacy bin, but these medications remained on the carts and available for use.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.