F0761

E

Improper Medication Storage in Resident Room and Undated/Expired Insulin Pens on Medication Cart

Lumberton, North Carolina Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to properly secure, label, and manage medications, including allowing medications to be stored in a resident’s room and maintaining expired medications. One cognitively intact resident had multiple medications stored on her bedside table, including a Simethicone bottle containing a Linzess capsule, two opened Biotin bottles (one with 1,000 mcg tablets and one with 5,000 mcg tablets expired in 04/2024), an opened Simethicone bottle expired in 01/24/2024, and a Clobetasol Propionate 0.05% spray. The Linzess capsule was being placed into an empty Simethicone bottle and left at the bedside, and the resident reported that nursing staff routinely left the daily Linzess capsule in that bottle on her bedside table.

Multiple staff interviews confirmed that nurses and medication aides had been placing Linzess capsules into the empty Simethicone bottle and leaving it in the resident’s room at her request, despite knowing medications should not be stored in resident rooms. One nurse acknowledged she had left the Linzess capsule in the Simethicone bottle without realizing the bottle was labeled for a different medication. Two medication aides reported that, over their respective periods of employment, they had routinely placed Linzess capsules into the bottle with the pink cap kept at the bedside. Another nurse stated she was aware that Linzess capsules were being stored in the labeled Simethicone bottle in the resident’s room until administration on specific days and admitted she had placed the capsules there even though she knew residents were not to have medications at the bedside.

A separate deficiency was identified on a medication cart, where an opened Novolog insulin pen had no documented open date and an opened Lantus insulin pen remained on the cart past its 11/24/25 expiration date, despite manufacturer instructions to discard 28 days after opening. Observation of the Lantana hall medication cart with a nurse revealed these issues, and the nurse stated that nurses and medication aides were responsible for checking carts daily for expired medications and ensuring insulin pens were dated when opened and discarded when expired. The DON stated her expectation that opened insulin pens be dated so staff could determine if they were still appropriate for use and that expired medications be removed from the cart.