Unattended Unlocked Medication Cart Observed
Summary
A deficiency occurred when a medication/treatment cart was observed unlocked and unattended in the 300's hallway. The surveyor noted the unattended cart and, upon inquiry, found that the assigned nurse was inside a resident's room. The nurse, identified as a wound care nurse, acknowledged that the cart should always be locked when unattended and admitted to leaving it unlocked by mistake while assisting a resident. The facility's policy requires all medications and biologicals to be stored in locked compartments with access limited to authorized personnel. The observation and subsequent interviews confirmed that the cart was not secured as required, resulting in a failure to properly store medications in accordance with federal regulations. There were 131 residents in the facility at the time of the survey.
Plan Of Correction
Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. On 06/18/2025, Assistant Director of Nursing provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. The Assistant Director of Nursing, or designee, will conduct random audits of medication/treatment carts. Audits will be no less than 5 audits weekly across all shifts for 3 weeks. Any deficiencies observed will be corrected immediately. No less than 5 audits will be completed monthly thereafter. The frequency of audits will be determined by the QAPI and QAA Committees. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Citation: F580 (D/ N199-Class: III, Isolated). Corrective actions will be accomplished for those residents found to have been affected by the deficient practice. Due to the date of the incident involving Resident #1 (01/23/2023), corrective action for notification could not be accomplished. On 1/24/2023, the Admissions Coordinator updated the demographic sheet to reflect Resident #1's Responsible Party/Emergency Contact. On 6/20/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Identification of other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly, to ensure that the resident's responsible party/emergency contact, if any, was notified of the treatment change. Identification of other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly, to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition for all incidents weekly for 2 weeks. Any problems with notification will be promptly resolved. Audits will then be conducted at random for 2 additional weeks of at least 20% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period. Any problems with notification will be promptly resolved. Monthly audits of at least 25% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period will be conducted to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Frequency of audits will be determined by the QAPI and QAA Committees. On 6/23/2025, the Admissions Coordinator notified the MDS Coordinator of the need to review the resident's demographics sheet to ensure that the resident's responsible party/emergency contact information, if any, is listed and is accurate during care plan meetings. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025. F0761 practice. On 6/22/2025, the Director of Nursing, or designee, observed all medication/treatment carts were locked as appropriate. No other carts were identified to be out of compliance at that time. On 06/18/2025, Assistant Director of Nursing provided education to Staff A on the need to ensure medication/treatment carts are locked when unattended. On 06/18/2025, Assistant Director of Nursing provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. On 06/18/2025, Assistant Director of Nursing, provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. The Assistant Director of Nursing, or designee, will conduct random audits of medication/treatment carts. Audits will be no less than 5 audits weekly across all shifts for 3 weeks. Any deficiencies observed will be corrected immediately. No less than 5 audits will be completed monthly thereafter. The frequency of audits will be determined by the QAPI and QAA Committees. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Opened glucometer test-strip containers on multiple units were found without an open date, and staff could not verify when they had been opened. Expired medications and supplies were also found in several medication carts and a medication room, including ointment, IV sets, feeding tubes, jelly, saline bullets, and a syringe. The DON stated the containers should have been labeled and acknowledged that expired items should not be present.
Loose pills were found in a medication cart drawer during an observation with an LVN. The pills were identified by the DON and ADON as Lisinopril/HCTZ, Oxybutynin, Eliquis, and Carvedilol. The LVN, DON, and ADM stated medications should be stored in blister packs or original manufacturer bottles, and the facility policy required drugs and biologicals to be stored in the packaging they were received in.
A resident approved for self-administration had multiple medications left unsecured in her room, including an inhaler, eye drops, nasal sprays, and nebulizer vials. The resident said her room did not lock and she did not have a lockbox, while an LPN was unsure whether room-kept meds needed to be locked and the DON confirmed the resident had not been offered a lockbox.
Unsecured Medication and Treatment Carts: An LPN left a medication cart unlocked in the hallway with the computer screen visible and a medication cup left on top while away from the cart for about 10-15 minutes. A treatment cart with prescribed ointments and creams was also observed unattended at the nurses’ station with residents nearby, and later the 300 unit medication cart was found partially unlocked with no nurse on the unit. The DON confirmed carts should be locked when unattended, and facility policy stated medication carts are always locked when out of sight or unattended.
A resident with multiple chronic diagnoses and a BIMS of 13 had opened Neosporin and prescription miconazole 2% ointment at the bedside without a care plan, self-administration assessment, or physician order authorizing bedside storage. The resident said he used the OTC and prescribed creams on his own, while the LVN, CMA, and DON stated they were unaware the medications were in the room and confirmed residents should not keep meds at the bedside without proper authorization.
Medication carts and a resident room had multiple storage and labeling deficiencies. An RN left a medication cart unlocked and unattended, a narcotic drawer on another cart was unsecured, and a third cart contained unopened insulin that was not refrigerated before opening plus multiple insulin pens, inhalers, and eye drops with no open date noted. Two bedside eye drop bottles in a resident room were also unlabeled.
Unlabeled Glucometer Strips and Expired Medications/Supplies Found in Storage Areas
Penalty
Summary
Drugs and biologicals used in the facility were not consistently labeled and expired medications and supplies were found in medication carts and a medication room. During observations on 8/12/26, opened glucometer test-strip containers without an opened date were found on the Willow, Susitna, Denali, and [NAME] units. Staff on those units confirmed they could not verify when the containers had been opened, and the DON stated the containers should have been labeled with the date, time, initials, and date opened. The facility also had expired medications and supplies in multiple storage areas. On 8/11/26, expired items were observed in the [NAME] Pass nurses’ station medication room, including triple antibiotic ointment packets, IV administration sets, and EnteraFlo gastrostomy feeding tubes. Additional expired items were found in the [NAME] medication cart, Denali medication cart, and Susitna medication cart, including Medihoney gel, hydrocortisone cream, saline bullets, lubricating jelly, antibacterial ointment, and a BD 1-mL syringe. Nurses verified the items were expired during interviews. The DON stated night shift charge nurses completed monthly audits of medications and supplies, but staff may have focused more on medications and forgotten other supplies. The DON also stated the person responsible for tracking lot numbers and upcoming expiration dates was supposed to send internal messages about items nearing expiration, and acknowledged that did not happen. Facility policy required medications and supplies to be clearly labeled, rotated, checked on a scheduled basis, and removed when expired or compromised, and the manufacturer’s guide for the glucometer strips required the date opened to be recorded on the bottle label.
Loose Pills Found in Medication Cart Drawer
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored properly in 1 of 1 medication carts reviewed. During observation of the medication cart with an LVN, four loose pills were found in a drawer of the cart. The LVN placed the pills in a dispensing cup and took them to the DON for identification. The loose pills were later identified by the DON and ADON as Lisinopril/HCTZ 100/12.5 mg, Oxybutynin 15 mg, Eliquis 2.5 mg, and Carvedilol 12.5 mg. During interviews, the LVN stated the medication cart should not have loose pills and that nursing staff were responsible for keeping the cart clean. The DON stated medications should be stored in blister packs or original medication bottles and was not aware there were loose medications on the carts. The ADM also stated medications should be stored in blister packs or manufacturer bottles and said the nurses were trained to use a small vacuum to clean the drawers. The facility policy stated drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received, and each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area.
Unsecured Self-Administered Medications in Resident Room
Penalty
Summary
The facility failed to ensure medications were securely stored when unattended for 1 of 5 hallways. Resident #41 had a physician’s order dated 07/06/26 allowing self-administration of medications, and the self-administration evaluation dated the same day stated the resident was completely capable and could demonstrate secure storage of medications kept in the room. However, during an observation on 08/10/26, an inhaler was seen unsecured on top of a small dresser under the resident’s television, and lubricant eye drops were unsecured on the bedside table. Further observations on 08/11/26 showed nasal sprays in an unlocked bathroom drawer, an inhaler in a wicker box on a dresser, and nebulizer vials on the nightstand. The resident stated the bedroom did not lock and that she would prefer a lock so other residents could not enter; she also stated she did not have a lockbox and did not know one could be requested. Staff B, LPN, stated the resident managed her own medications but was unsure whether medications kept in the room needed to be locked. The DON stated the resident kept inhalers and artificial tears in the room, oral medications were locked in the medication cart, and the resident had not been offered a lockbox. The facility policy stated bedside storage is permitted only when medications are stored safely and securely, with lockable drawers or cabinets required if needed.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure medications were stored in a locked secure manner. On 08/10/2026 at 2:38 PM, while observations were being made on the 300 unit, a medication cart was seen in the hallway outside room [ROOM NUMBER] with the cart unlocked, the computer screen visible with resident information displayed, and a small clear medication cup containing a small greenish-white tablet sitting on top of the cart. Staff B, an LPN, walked away from the cart to the nurses’ station and was out of view of the cart for approximately 10-15 minutes while residents passed by in the hallway. When interviewed, Staff B confirmed the cart should have been locked, the computer screen closed, and medication should not have been left unattended. On 08/12/2026 at 09:00 AM, a treatment cart was observed at the nurses’ station with prescribed ointments and creams for topical use sitting on top of the cart unattended while approximately 6-7 residents were seated at the nurses’ station and 2 residents walked by the cart. Later that morning, the 300 unit medication cart was observed with the lock halfway pushed in, leaving the cart unlocked, and no nurse was observed on the unit. The DON later confirmed that medication carts should always be locked when unattended and that medications should never be left on top of medication or treatment carts. The facility policy stated that medication carts are always locked when out of sight or unattended.
Unauthorized Bedside Medication Storage
Penalty
Summary
The facility failed to ensure that drugs were stored in a locked compartment and that medications at the bedside were authorized for Resident #11. Resident #11 was admitted with diagnoses including hypertension, heart failure, schizoaffective disorder bipolar type, chronic pulmonary edema, anxiety disorder, and adult failure to thrive. His admission MDS indicated he was usually understood or usually understood others, had clear speech, and had a BIMS of 13, indicating he was cognitively intact for decision making. The electronic record showed no care plan addressing bedside medications or self-administration, no self-administration medication assessment, and no physician orders for Neosporin or prescribed miconazole 2% ointment to be kept at the bedside. During the initial tour, surveyors observed an opened and used 1-ounce tube of Neosporin with no pharmacy label on the bedside table and an opened and used tube of prescription-labeled miconazole 2% ointment on the bedside nightstand. When interviewed, Resident #11 said he used Neosporin on his groin when it was dry and to prevent infection, that he ordered it from Amazon about two weeks earlier, and that he used the miconazole 2% ointment on his feet for itching. He said the nurses left the miconazole in the room one day, but he could not remember when, and he had not told staff because he did not think he needed to report over-the-counter medications and did not see a point since the areas had cleared up. Staff interviews showed that the LVN and CMA were not aware of medications being left at the bedside and stated residents should not have medications at the bedside without a physician order and self-administration assessment. The DON stated she was not aware of the medications at the bedside, confirmed there was no order for Neosporin or miconazole 2% to be left at bedside, and confirmed no self-administration assessment had been completed. The facility policy stated bedside medication storage is permitted only under specific conditions, including an assessment of the resident's ability to self-administer and storage that prevents access by other residents, and that unauthorized bedside medications are to be reported and given to the charge nurse.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications in four medication carts and one resident room, with observations showing unsecured carts and improperly labeled or stored medications. During a medication pass, an RN walked into a resident room and left the 2B Medication Cart unlocked and unattended, and later the narcotic drawer on the 2C2 Medication Cart was observed unlocked and unsecured while the cart sat unattended in the hallway. An RN confirmed both conditions during interview. On another observation, the 2A Medication Cart contained multiple medication storage issues, including unopened insulin vials and pens that were not refrigerated before opening, several insulin pens and inhalers with no open date noted, and eye drops with no date noted. The cart also contained an open Lantus vial with no open date. In the 1B Medication Cart, Latanoprost eye drops were dated 6/8/26. In a resident room, two bottles of eye drops at bedside were not labeled with an open date, and an RN confirmed the bottles failed to be labeled as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 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.