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F0609
D

Failure to Immediately Report Suspected Misappropriation of Medication

Mount Horeb, Wisconsin Survey Completed on 08-13-2025

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

A deficiency occurred when an LPN failed to immediately report a suspicion of misappropriation of medication as required by facility policy and state law. The incident began when a Registered Nurse/Infection Preventionist (RN/IP) requested and took the keys to the medication cart from the LPN, accessed the cart, and later stated they had found what they were looking for. The LPN, suspecting that medication may have been taken, performed a count of the narcotic medications and found the count to be correct, but noted that there was no way to verify the count of other medications. Despite suspecting possible misappropriation, the LPN did not report the concern to the Nursing Home Administrator (NHA) or Director of Nursing (DON) as required by facility policy. During interviews, the LPN acknowledged awareness of the requirement to report suspicions of misappropriation to the DON or NHA but admitted not doing so. The NHA confirmed that staff are expected to immediately report such suspicions and that no report had been made by the LPN regarding this incident. Facility policies reviewed by the surveyor clearly state that any suspicion of misappropriation must be reported immediately to the administrator and appropriate authorities for investigation.

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