Controlled Substances Storage Boxes Not Permanently Affixed in Medication Rooms
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage of controlled substances in two medication rooms. On multiple occasions, the storage box for controlled substances on the second floor was found placed on top of the refrigerator rather than being secured inside and permanently affixed. In the third-floor medication room, the controlled substances box was inside the refrigerator but was not permanently affixed as required. These findings were consistent over several days of observation. During an interview, a registered nurse confirmed that controlled substances requiring refrigeration were kept in the refrigerators and counted every shift, but did not address the lack of permanent affixation. The findings were reviewed with facility leadership during the exit conference. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.