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F0761
D

Unauthorized Access to Narcotic Keys by Medication Aides

Darlington, Wisconsin Survey Completed on 10-15-2025

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

The facility failed to ensure that only authorized staff had access to the keys for the locked narcotic box and medication storage room. Observations showed that two Certified Medication Aides (CMAs) were in possession of the keys to the medication cart and the locked narcotic box, despite facility policy and their job descriptions explicitly stating that CMAs are not permitted to pass or access narcotic medications. Both CMAs confirmed during interviews that they held the keys during their shifts and participated in verifying narcotic counts with the narcotic binder, although they stated they did not administer narcotics to residents. Interviews with nursing staff, including an LPN and an RN, confirmed that only nurses are allowed to dispense narcotic medications. Review of facility policies indicated that the responsibility for the keys to Schedule II medication storage areas lies solely with nurses, and access to these keys should be limited to those who require them. The Administrator and Director of Nursing acknowledged that the CMAs should not have had access to the narcotic box keys, confirming this was contrary to facility policy. No information was provided regarding any specific residents affected or their medical conditions at the time of the deficiency.

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