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F0761
D

Failure to Maintain Proper Medication Storage Temperatures

Booker, Texas Survey Completed on 04-30-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medications were stored in accordance with accepted professional principles in the medication room refrigerator. Review of the refrigerator temperature logs for April 2025 showed multiple instances where the temperature was recorded at 32 degrees Fahrenheit, which is the freezing point of water. Medications stored in the refrigerator at the time of observation included an Ozempic insulin pen labeled 'Do Not Freeze' and two Lantus insulin pens labeled to be stored between 36 to 46 degrees Fahrenheit. Both RN A and the ADON acknowledged that 32 degrees is considered freezing and that freezing could affect the medications, but neither could confirm if the medications had actually frozen. The DON also confirmed that storing medications outside their recommended temperature range could affect their longevity and potency. The facility's policy on medication storage, effective January 2024, requires that medications with specific storage requirements for temperature, light, or humidity must be stored according to those specifications. Despite this policy, the medication room refrigerator was not consistently maintained within the required temperature range for the medications stored inside. There was no documentation or evidence provided that staff took action to address the out-of-range temperatures or to assess the integrity of the affected medications.

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