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F0761
E

Improper Storage and Labeling of Medications and Biologicals

Watertown, Massachusetts Survey Completed on 05-06-2025

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 drugs and biologicals. One resident, admitted with dysphagia and hemiplegia and assessed as cognitively intact, was observed with an open container of nicotine lozenges on the over-bed table, including partially dissolved lozenges, despite a documented evaluation indicating the resident was unable to self-administer medications. Staff interviews confirmed that the resident was not permitted to self-administer and that medications should not be left at the bedside, yet the lozenges were found unsecured. Further observations of medication carts on several floors revealed additional issues: open and undated bottles of liquid protein supplements (proheal and prostat) that require dating upon opening, numerous loose pills in medication cart drawers, an expired insulin pen, and an unlabeled, undated syringe filled with clear liquid (insulin) stored loosely in a drawer. Staff interviews confirmed that these practices were inconsistent with facility policy and manufacturer guidelines, which require proper labeling, dating, and secure storage of all medications and biologicals.

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