Medication Security and Expired Medications in LTC Facility
Summary
The facility failed to properly lock and secure medication carts on the Overlook Point Unit, creating a situation where medications could be accessed without the nurse's awareness. During observations, both an LPN and an RN were seen leaving medication carts unlocked and unattended. The LPN left the cart unlocked after retrieving medication and walked away, while the RN left the cart with a drawer open and unattended. The Director of Nursing acknowledged that the LPN had reported the incident and received verbal education, but no further education was provided to other nurses. The facility had residents with the potential to wander, increasing the risk of unauthorized access to medications. Additionally, the facility did not ensure that the emergency kit contents were replaced and that medications were not expired. An observation revealed an open, undated vial of Humulin R Insulin in the emergency kit, missing insulins, and an expired IV start kit in the medication room. An expired Epinephrine auto-injector was also found in a medication cart. The pharmacist consultant's findings indicated that emergency medication services conformed with regulations, but the facility's staff and the pharmacist did not identify the expired medications during their reviews. The State Agency determined that the facility's non-compliance with federal health, safety, and quality regulations was likely to cause serious harm. The Administrator was notified of the Immediate Jeopardy situation due to the failure to monitor medication carts when unattended. The facility provided an acceptable Immediate Jeopardy Removal Plan, which was validated by the survey team, but the facility remained out of compliance at a lower scope and severity.
Removal Plan
- Medication Cart Secured Immediately: All medication carts have been locked in the designated medication rooms on each unit. Access to the carts has been restricted to authorized personnel only, ensuring the safety and security of medications. Any previously unlocked medication carts have been secured to prevent unauthorized access.
- Staff Re-Education and Re-Training: The nurse identified as leaving the medication cart unlocked was provided one-on-one education by the DON. The training covered the correct procedure for locking medication carts and emphasized the importance of cart security. In addition, all nursing staff (Registered Nurses) RN's and LPN's on duty have been re-educated on the same procedures by the DON or administrator. The focus was on the correct procedure for locking medication carts at all times when not in use and the importance of maintaining medication cart security.
- Observation and inspection of Medication Cart: Maintenance staff conducted an inspection of the medication carts to verify that the locks are functioning properly.
- Notification of Medical Director and QAPI: The Medical Director was notified of the alleged Immediate Jeopardy related to the unlocked medication cart. An Ad-Hoc QAPI meeting was held to discuss the plan of correction and review actions taken to address this issue.
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.
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