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F0761
E

Deficient Storage and Labeling of Medications and Vaccines

Colorado Springs, Colorado Survey Completed on 06-26-2025

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 identified multiple deficiencies in the facility's storage and labeling of medications and biologicals. Vaccines were found stored in a dormitory-style refrigerator, which is not approved for vaccine storage according to CDC guidelines. The refrigerator lacked a thermometer for temperature monitoring, and staff were unaware that such a refrigerator was inappropriate for vaccine storage. Expired vaccines, including COVID-19, Prevnar 20, and Influenza vaccines, were present in the refrigerator, and a vial of Tubersol was found without an open date, contrary to manufacturer instructions that require discarding after 30 days of use. Medication carts were also found to be noncompliant with professional standards and facility policy. Creams and ointments were stored together with inhalers and nasal sprays, rather than being separated by route of administration. Loose pills and capsules were found in the medication drawers, and topical lidocaine patches were not kept in their original packaging, which could compromise their effectiveness. Staff interviews confirmed that these storage practices did not align with facility policy or professional standards. The facility's policies require medications and biologicals to be stored securely, labeled properly, and separated by route of administration. Outdated or improperly stored medications are to be removed immediately, and temperature monitoring for refrigerated items is mandated. However, observations and staff interviews revealed that these procedures were not consistently followed, resulting in the deficiencies cited.

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