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F0761
E

Improper Storage and Security of Medications

Kerrville, Texas Survey Completed on 07-31-2025

Penalty

Fine: $127,4206 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 that two medications requiring refrigeration, Latanoprost ophthalmic solution and promethazine suppositories, were stored in a medication cart drawer instead of the medication refrigerator. Both medications were labeled with blue stickers indicating that refrigeration was required. During an interview, the Assistant Director of Nursing confirmed that these medications should have been stored in the medication refrigerator and acknowledged that improper storage could result in harm to residents. The facility's policy also specifies that all medications requiring refrigeration must be stored in designated refrigerators located in the pharmacy and medication rooms. Additionally, the 300-hall medication cart was found unlocked and unattended in the hallway near the nurses' station, with four residents present in the immediate area. No staff were present during the observation period, and no residents were seen accessing the cart. Upon returning, an LVN admitted responsibility for the unlocked cart and stated that facility policy requires the cart to be locked when not in use. The facility's policy further mandates that medications must be under direct observation or locked during medication pass.

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