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F0761
E

Expired and Unlabeled Medications Found in Use

Salt Lake City, Utah Survey Completed on 06-19-2025

Penalty

Fine: $13,000
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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 that the facility failed to ensure drugs and biologicals were labeled and stored according to professional standards for four residents. Specifically, expired medications were found in use, including Ketotifen Fumarate eye drops administered to a resident after the labeled open date had passed, and an insulin pen that was past its expiration date. Additionally, several eye drop bottles, both prescription and over-the-counter, were found without open dates, making it impossible to determine if they were still safe for use. Staff interviews confirmed that medications such as eye drops and insulin are expected to be discarded after a set period post-opening, but this protocol was not consistently followed. The observations included a nurse administering expired eye drops, multiple medication carts containing opened eye drops and insulin pens without proper labeling, and staff acknowledging the lack of required open dates or the presence of expired medications. Medication administration records confirmed that these medications were actively being given to residents. The Director of Nursing and other staff stated that all opened eye drops and insulin should be discarded after 28 days, but this was not adhered to, resulting in the use and storage of expired or improperly labeled medications.

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