F0761

E

Improper Medication Labeling, Expired Drugs, and Inadequate Security for Controlled Substances

Peoria, Illinois Survey Completed on 12-22-2025

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s handling, labeling, and storage of medications, including controlled substances, based on observations of medication carts and a medication room, as well as staff interviews and policy review. The facility’s policies required that no discontinued, outdated, or deteriorated drugs be retained for use, that all multi-use medications be properly labeled and legible, and that all controlled substances be stored under double lock and key. Despite these policies, one medication cart contained multiple opened insulin vials and a bottle of levetiracetam liquid without documented dates of opening for several residents, and multiple expired medications including insulin glargine, Latanoprost ophthalmic solution, Breo Ellipta inhalers, Anoro Ellipta inhalers, and a Basaglar KwikPen. Nursing staff confirmed that these medications were either missing required open dates or were expired and should have been discarded.

In addition, surveyors observed that the medication room contained an unlocked refrigerator with drawers designated for controlled substances, and those drawers were not locked. A lorazepam 0.5 mg IM (Schedule IV) medication for one resident was found stored in an unlocked drawer, contrary to the facility’s policy requiring all controlled substances to be stored under double lock and key. Registered nurses and the Director of Nursing acknowledged during interviews that multi-use medications must be labeled with the date opened, expired medications must be discarded appropriately, and controlled substances must be double locked, confirming that the observed conditions did not comply with facility policy and accepted standards for medication storage and labeling.