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F0761
E

Expired Medications, Incomplete Crash Carts, and Improper Medication Storage Identified

Grass Valley, California Survey Completed on 08-22-2025

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 observed that medications and medical supplies stored in three medication carts were expired, including haloperidol, isopropyl alcohol, Microkill One wipes, Maxorb II wound dressing, antiseptic skin cleanser, extra protective cream, anti-itch cream, iodoform packing strip, hydrogen peroxide, phenazopyridine tablets, skintegrity wound cleanser, biofreeze gel, syringes, and catheter stabilization devices. Additionally, an unlabeled pill identified as methadone was found in a narcotic box, and opened petrolatum dressings were present in the cart. Licensed nurses confirmed the presence of these expired and improperly stored items, acknowledging the importance of removing expired medications and supplies to prevent their use. Crash carts, which are essential for emergency situations, were not checked daily as required by facility policy, with multiple days missed from May to August. Inspections revealed that the crash carts did not contain the required number of normal saline containers, instead containing sterile water, and included a suction connection tubing that had expired in 2011. The Director of Nursing confirmed these discrepancies and the lack of regular checks, which are necessary to ensure the readiness and completeness of emergency equipment and supplies. A medication bottle containing acidophilus probiotic was found stored in a refrigerator designated for resident food in the memory unit. Both a certified nursing assistant and a licensed nurse confirmed that medications were being stored with food, which posed a risk for cross contamination. The Director of Nursing stated that medications requiring refrigeration should be kept in a secured medication refrigerator, not with resident food. Facility policies reviewed indicated that outdated, contaminated, or deteriorated medications should be removed from stock and that refrigerated medications must be kept separate from foods.

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