Deficiencies in Medication Storage, Labeling, and Sanitation
Penalty
Summary
Surveyors identified several deficiencies related to the storage, labeling, and disposal of medications and biologicals. During inspections of medication storage areas, it was observed that medication cabinets were dusty and not maintained in a clean and sanitary condition, as acknowledged by a registered nurse. Additionally, a bottle of geri-tussin was found with an illegible expiration date, and the nurse confirmed that expiration dates should be legible for resident safety. The facility's policy requires that medications be stored safely, securely, and properly, and that storage areas are kept clean and free of clutter. Further inspection of a treatment cart revealed multiple packets of Dermaseptin ointment and Dermarite Boarder Gauzes without expiration dates after being removed from their original packaging. A licensed vocational nurse confirmed that these items should have been labeled with expiration dates when removed from the original box. The facility's policy also states that outdated, contaminated, or deteriorated medications, or those in compromised containers, should be immediately removed and disposed of according to procedure. The Director of Nursing was informed and acknowledged these findings.
Plan Of Correction
F 761 F761 Label/Store Drugs and Biologicals Corrective Action Initiated For Resident/s On 6/16/25, medication room A cabinets were immediately cleaned, disinfected, and the hanger was removed by ADON. On 6/16/25, the bottle of Geri-Tussin with an illegible expiration date was removed and discarded from Medication Room B by ADON. On 6/16/25, all Dermaseptin ointment packets and Dermarite bordered gauze without visible expiration dates were removed. New supplies with expiration dates verified from the original box were placed in a clear container with clear expiration dates labeled by the treatment nurse on 6/16/25. How Potential Other Residents Were Identified and Corrective Action Taken Other residents are at risk for this noted practice. On 6/17/25, a spot check of medication and treatment rooms, carts, and storage areas was initiated. No additional issues were found during this audit. Measures to Prevent Recurrence Systemic The DON/designee conducted an in-service training on 7/3/25 to all licensed nursing staff on P&P on Medication Storage, labeling, and emphasizing proper labeling and visibility of expiration dates for all medications and supplies, as well as the importance of a cleaned and sanitary medication area. The ADON/designee will conduct weekly audits for four weeks, then monthly for three months to validate that medication storage areas remain clean and free of unnecessary items, and to ensure that all medications and treatment supplies are clearly labeled with expiration dates. Any findings will be reported to DON for follow-up. Monitoring Plans to Ensure Solutions are Achieved and Integrated into QA System The POC is integrated into the QA system. The DON/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for three months or until such time that consistent substantial compliance has been achieved, as determined by the committee. Date of compliance: 7/3/25