Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices across four medication carts. An undated and unlabeled bottle of Systane eye drops was found in the Station 1 south-hall medication cart, with no resident name or label to identify ownership. Additionally, three loose, unidentified pills were found in the Station 1 east-hall medication cart, one loose pill in the Station 2 south-hall cart, and eighteen loose, unidentified pills in the Station 2 north-hall cart. An expired bottle of magnesium oxide, labeled with a best by date of 02/2025, was also found in the Station 2 north-hall cart. Staff interviews confirmed that nurses were responsible for maintaining the order and cleanliness of the medication carts, and that medications should be dated when opened and stored in their original containers. Despite these expectations, the observations revealed that medication carts were not consistently maintained according to facility policy and professional standards. Staff members acknowledged that loose pills should not be present in the carts and that dropped pills should be removed immediately. The Director of Nursing and Assistant Administrator both stated that the findings did not meet their expectations for medication storage. Review of the facility's procedure for medication storage confirmed that drugs should be stored in an orderly manner and in their originally received containers, which was not followed in these instances.