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F0689
D

Failure to Secure Medications and Assess for Self-Administration

Tullahoma, Tennessee Survey Completed on 06-11-2025

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

The facility failed to ensure that medications were stored and secured properly for two residents. According to facility policy, medications are to be stored safely, securely, and only accessible to licensed nursing personnel, with medications kept in a medication cart unless a resident has been assessed for self-administration. For one resident with heart failure, pancreatic cancer, and anxiety, an Incruse Ellipta inhaler was observed left on the bedside table after administration by an RN, who confirmed that the resident had not been assessed for self-administration. Similarly, for another resident with a history of joint replacement and emphysema, an unopened vial of Budesonide Inhalation Suspension was found on the bedside table after administration by an LPN, who also confirmed the absence of a self-administration assessment in the medical record. Both the RN and LPN acknowledged that medications should not be left at the bedside unless the resident has been properly assessed for self-administration, and the DON confirmed that neither resident had such an assessment documented. Observations and interviews confirmed that the medications were not secured or stored according to facility policy, and that the medications were accessible to the residents without proper authorization or assessment.

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