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F0761
D

Unattended Unlocked Medication Cart and Improper Medication Labeling

San Rafael, California Survey Completed on 08-21-2025

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

A medication cart was observed left unlocked and unattended in the hallway by an LVN, who walked away into a resident's room, leaving the cart accessible. The LVN later confirmed that the cart was left unlocked and unattended, acknowledging this was a mistake. The facility's policy and procedure require that medication carts be locked when not in use to prevent unauthorized access, and the DON confirmed that carts should always be locked when unattended. Additionally, an open bottle of Senna syrup was found in a medication cart without an expiration date and not in its original packaging. The LVN present stated that the Senna syrup needed to be discarded due to the missing expiration date and lack of original packaging. The DON and the facility's pharmacist both confirmed that medications should be kept in their original packaging with the expiration date visible, and the facility's policy supports this requirement.

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