F0761

E

Unlocked Medication Cart on Memory Care Unit

Los Alamos, New Mexico Survey Completed on 12-19-2025

Penalty

Fine: $47,075

Summary

Surveyors identified a deficiency related to improper storage and security of medications when a medication cart on the memory care unit was observed unlocked and unattended for an extended period. On 11/18/25 at 2:00 p.m., during a random observation and interview on the memory care unit, the medication cart was found unlocked in the back of the unit with one resident standing next to it and another resident walking back and forth nearby. The cart remained unlocked from 2:00 p.m. to 2:33 p.m. The Housekeeping Director, when asked if the medication cart should be left unlocked, stated it should not and then left to look for the DON, leaving the cart still unlocked. A CNA, when asked if the medication cart should be unlocked, also stated it should not be and likewise walked away to look for the nurse, leaving the cart unsecured until she returned a few minutes later and locked it.

At 2:32 p.m., during an interview, the DON confirmed that the medication cart was unlocked and stated that medication carts should be locked when not in use. The report notes that this failure to ensure medications were stored properly and that medication carts were locked and secured when not in use was a deficient practice that could result in resident injury through dosing with improperly stored medications, access to medications not prescribed for them, and possible overdose.