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F0761
E

Medication Storage and Disposal Deficiencies

Traverse City, Michigan Survey Completed on 06-12-2025

Penalty

Fine: $119,41525 days payment denial
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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 observed multiple deficiencies in the facility's medication storage and disposal practices. During an environmental tour, five loose medications were found between the seat cushions of a chair in a hallway, accessible to residents and not secured. Additionally, three medication carts on the Maple Unit and two on the Cherry Unit were reviewed, revealing loose tablets in two carts and an expired insulin pen in another. The insulin pen had been discontinued per physician order, but remained in the cart past its discard date. In one instance, an RN was observed disposing of unidentified medications from a plastic cup found in a medication cart by dumping them into a standard refuse receptacle, without knowledge of what the medications were or who they belonged to. Interviews with nursing staff and review of facility policies confirmed that medications should not be pre-set, must be prepared at the time of administration, and should be disposed of using a designated medication disposal system (Drug Buster®), not in regular trash. The facility's policies also require that medications be stored securely and only accessible to authorized personnel. The observed practices did not align with these policies, as medications were found unsecured, improperly stored, and inappropriately disposed of.

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