F0755

E

Improper Storage and Packaging of Controlled Substances

Lemont, Illinois Survey Completed on 08-21-2025

Penalty

Fine: $22,260

Summary

Surveyors identified a deficiency in the facility’s handling and storage of controlled substances when multiple medication packages were found broken and taped over rather than remaining fully sealed in their original packaging. During medication room and cart observations conducted on all three floors, surveyors, accompanied by nursing staff, observed that specific unit-dose packages of controlled medications for seven residents were compromised. These included Lorazepam 0.5 mg tablets for one resident at tablet number 18, another at tablet number 27, and a third at tablet number 16; Triazolam 0.25 mg tablets at tablet numbers 1 and 5 for another resident; Hydrocodone/APAP 5-325 mg at tablet number 20 for another resident; Tramadol 50 mg at tablet number 12 for another resident; and Oxycodone HCL 5 mg at capsule number 29 for another resident. In each instance, the packaging was described as broken and then taped over.

The DON stated that staff are required to ensure controlled substances remain in their original packaging and are completely sealed to maintain complete accountability of each tablet or capsule. The facility’s March 2021 medication storage policy requires medications and biologicals to be stored safely, securely, and properly, following manufacturer or supplier recommendations. The controlled substance storage policy further specifies that medications classified by the DEA as controlled substances are subject to special handling, storage, disposal, and recordkeeping in accordance with federal, state, and other applicable laws and regulations. The observed practice of storing controlled substances in broken, taped-over packaging was inconsistent with these stated requirements.