Improper Medication Labeling and Unsecured Heparin Syringe
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on a medication cart and in a resident room. During an observation of the 500 hall long-side medication cart with a nurse, surveyors found an opened and undated Novolog insulin flex pen in the top drawer, with a pharmacy label showing it was filled on 11/10/25. Manufacturer instructions indicated the pen was usable for 28 days after first use, but the nurse stated she did not know whether the expiration was 28 or 30 days after opening and confirmed it should have been dated. She reported she had administered insulin from this pen that morning and had not noticed it was undated. The same cart also contained an open bottle of Acidophilus tablets with a manufacturer’s expiration date of 11/25 and approximately 40 tablets remaining, indicating the stock medication was expired but still available for use. The nurse stated she had not administered any of the Acidophilus and that she only checked expiration dates on stock medications she used during her shift, rather than all stock medications in the cart. In a separate incident, the facility failed to secure a heparin flush syringe, leaving it accessible in a resident’s room. A resident with a prior physician’s order for heparin lock flush solution 10 units/mL, 5 mL IV every shift for PICC line patency, had that order discontinued on 12/15/25. On observation of the resident’s room, surveyors found a syringe in a sealed bag on a shelf next to the resident’s chair, labeled as heparin lock flush solution 5 mL and partially full. A nurse confirmed the syringe contained medication and removed it from the room, stating he had given the resident medications earlier that day but had not seen the syringe on the shelf and did not know who had left it there. The DON later stated that medications should never be left in a resident’s room and the Administrator stated that medications should not be kept at bedside unless there was an order for self-administration of medication.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.