F0761

E

Improper Storage and Expired Use of Controlled and Refrigerated Medications

Hillsboro, Illinois Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to properly secure and store controlled medications and to discard expired medications for seven residents reviewed for medication storage. During inspection of the medication room, the refrigerator was found unlocked while containing a resident’s bottle of oral lorazepam concentrated solution, despite facility policy requiring biologicals or medications requiring refrigeration to be kept in a securely fastened or locked refrigerator system. On a medication cart, an open and partially used vial of insulin glargine solution for another resident was found with a handwritten open date of 1/5/26, while the manufacturer’s expiration date on the vial was November 2025, indicating the insulin was in use past its expiration date.

Further inspection of another medication cart on a different hall revealed that the lock box intended for controlled substances was unlocked and could be opened simply by lifting the lid. Inside this unlocked lock box were multiple open and unopened controlled medications in active use for several residents, including morphine sulfate oral solution, lorazepam concentrated solution, oxycodone, hydrocodone/APAP, alprazolam, and tramadol tablets. A LPN acknowledged that the lock sometimes gets stuck and does not latch, and verified that these controlled medications were in use while stored in the unlocked lock box. Another LPN later stated that all narcotics and controlled medications are supposed to be under a double-locked system, and that controlled medications in the refrigerator and on the medication cart should be secured according to this standard, as reflected in the facility’s written policies on storage of drugs and Schedule II controlled substances.