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F0761
D

Failure to Properly Label and Secure Medications

Berlin, Maryland Survey Completed on 07-23-2025

Penalty

Fine: $20,685
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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

Surveyor observations and staff interviews revealed that the facility failed to ensure proper labeling and storage of drugs and biologicals, as well as secure medication storage. During medication administration on the 300 unit, a Certified Medication Aide (CMA) was observed using a bottle of Senna Plus (sennosides-docusate sodium) that was not labeled with the date it was opened, despite the facility's practice requiring such labeling. The bottle was already opened and approximately half empty at the time of observation. The CMA confirmed that bottles should be dated when opened and proceeded to label the bottle after the surveyor's inquiry. The Regional Nurse Consultant, Licensed Nursing Home Administrator, and Director of Nursing were all notified of this finding. Additionally, a medication cart was found unlocked and unattended in a hallway, with all drawers accessible and no staff present nearby. A Geriatric Nursing Assistant (GNA) later locked the cart, stating the responsible nurse was assessing a patient elsewhere. The nurse later confirmed she had left the cart unlocked because she intended to return shortly, and the Director of Nursing acknowledged that the cart should have been locked when not in the nurse's view. Review of facility policy confirmed that medication carts are required to be locked when not in use and in direct line of sight.

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