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F0761
E

Medication Storage, Labeling, and Temperature Control Deficiencies

Danvers, Massachusetts Survey Completed on 06-18-2025

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 related to the storage and labeling of medications and biologicals. On one nursing unit, a medication cart was observed left unlocked and unattended, allowing access to medications by unauthorized individuals, including residents who were seen walking past the cart. The nurse responsible for the cart was unaware it was unlocked, and both the nurse and the Director of Nursing confirmed that medication carts are required to be locked at all times when not in use. Additionally, medications on one of the medication carts were not labeled or dated according to manufacturer guidelines. Specifically, a bottle of Artificial Tears Lubricant Eye Drops was found open and undated, and the nurse present could not confirm when it had been opened. The Director of Nursing stated that medications should be dated upon opening and that staff are expected to document this information on the bottle. Further deficiencies were found in the storage of medications requiring refrigeration. The medication refrigerator lacked a functioning thermometer, and temperature logs were incomplete, with only 12 out of 30 days documented for one month. The refrigerator was observed to be too warm, with condensation and melting frost present, and medications inside were wet to the touch. The Assistant Director of Nursing acknowledged the refrigerator was not maintaining proper temperature and that there was no record of how long it had been out of range. The Director of Nursing was unaware of the issue and stated that the affected medications would need to be discarded due to unknown temperature exposure.

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