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F0761
E

Failure to Secure Controlled Substances and Appropriately Label Opened Medications

Gettysburg, Pennsylvania Survey Completed on 06-12-2025

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 observed that controlled substances, specifically lorazepam, were not properly secured in the medication storage room refrigerator in Arlington Hall. One bottle of lorazepam was found lying on top of the non-removable lock box, and the lock box itself was not locked, containing seven additional vials of lorazepam. Facility policy requires that controlled substances be double locked, and staff confirmed that the lorazepam should have been stored inside the locked box. Additionally, during inspection of two medication carts (2-AE and 2-A hall), multiple open bottles of medications, including acetaminophen, cranberry tablets, calcium with vitamin D, multivitamins, and prosource powder, were found without open dates. Facility policy mandates that all multi-dose vials be dated when opened. Staff interviews confirmed that the expectation is for medications to be dated upon opening, but this was not followed in the observed instances.

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