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F0761
E

Medication Storage and Labeling Deficiencies Identified

Castro Valley, California Survey Completed on 06-20-2025

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 identified multiple deficiencies related to medication storage and labeling within the facility. One resident's Latanoprost eyedrops were found stored in the medication cart beyond the 42-day use-by date, despite clear labeling on the medication box and confirmation from both the MDS Coordinator and the DON that the medication should have been discarded after the specified period. Additionally, six vials of Retacrit, a medication for anemia, were found in the medication room refrigerator belonging to a resident who had been discharged several days prior. The DON confirmed that medications for discharged residents should be disposed of on the day of discharge to prevent medication errors. Further observations revealed an opened and unlabeled Lispro insulin vial in the medication room refrigerator. The LVN and DON both stated that insulin vials should be labeled with the resident's name and the date opened. During medication administration, a nurse gave a resident Metoclopramide from a medication card with directions that did not match the current physician's order. The nurse stated she followed the physician's order, but the DON acknowledged that the medication card should have been updated to reflect the change in directions. Additional deficiencies included the discovery of 18 loose, whole tablets scattered underneath medication cards in a medication cart, which staff could not identify and stated should be disposed of according to policy. Suppositories belonging to two discharged residents were also found in the medication cart, despite facility policy requiring immediate disposal of such medications upon discharge. These findings were corroborated by interviews with nursing staff and a review of facility policies regarding medication labeling, storage, and disposal.

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