Medication Carts Left Unattended and Unlocked
Penalty
Summary
Surveyors observed that three medication carts were left unattended and unlocked in multiple units of the facility. On several occasions, medication carts containing resident medications, over-the-counter drugs, diabetic supplies, lancets, narcotic medications, medicated patches, and alcohol pads were accessible while nursing staff were not present or were inside resident rooms. These observations were confirmed by staff interviews, where nurses acknowledged that leaving carts unlocked and unattended was not consistent with facility policy or their usual practice. The fill-in Director of Nursing and LPN Manager also confirmed that medication carts should not be left unlocked when unattended. A review of the facility's policy on Medication Labeling and Storage, revised in December 2025, indicated that all compartments containing medications and biologicals must be locked when not in use, and carts used to transport such items should not be left unattended if open or accessible. Despite this policy, surveyors were able to access medication carts without restriction, and staff confirmed the presence of controlled substances and diabetic supplies in these carts at the time of the observations.