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F0761
E

Improper Storage and Pre-Preparation of Medications in Medication Cart

Oregon City, Oregon Survey Completed on 06-06-2025

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

Surveyors found that the facility failed to ensure proper storage of biologicals and medications in accordance with its own policies and accepted professional standards. During observation, six plastic medication cups containing medications and labeled only with resident room numbers were found in the top drawer of a medication cart, and an additional unlabeled medication cup with pills was found in the narcotic locked box of the same cart. These medications were pre-prepared for administration to multiple residents, including those receiving medications such as atorvastatin, gabapentin, sertraline, simvastatin, docusate, topiramate, dicyclomine, prazosin, senokot, trazodone, buspirone, Tylenol, calcium supplements, icosapent, baclofen, Prilosec, hydroxyzine, risperdal, sucralfate, morphine, dilaudid, aripiprazole, mirtazapine, and tamsulosin. A certified medication aide (CMA) acknowledged that she routinely prepped scheduled medications early and left them in the medication cart, labeling the cups with room numbers and placing them in the top shelf or narcotic drawer. She stated this was her usual process due to challenges in administering medications in a timely manner, and admitted it was not best practice. The Director of Nursing confirmed the presence of pre-prepped medications in the cart and acknowledged that this was not proper medication storage.

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