F0761

E

Unsecured Medications and Improper Self-Administration Practices

Fairlawn, Ohio Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to securely store and properly administer medications in accordance with professional standards and facility policy. During observation on the west hall, an unlocked medication cart was found unattended with eight medication cups containing pills on top of the cart, each cup labeled with letters corresponding to resident names. LPN #300 acknowledged she had preset 11:00 A.M. medications for multiple residents, written their names on the cups, and left the cart and medications unsupervised in the hallway while she was in a resident’s room. She confirmed the specific number of pills preset for each identified resident. The DON later stated that nurses should not preset medications and that medications were to be prepared and administered at the same time, one resident at a time.

A second deficiency was identified on the memory care unit involving a resident with dementia who was assessed as severely cognitively impaired on a recent MDS and resided on the Memory Care Unit. Observation revealed this resident lying in bed with the door open and a bedside table in front of her, on which there was a medication cup containing nine medications of various pill sizes and capsules, with no staff present nearby. LPN #302 confirmed she had completed her medication pass and had left the medications in the resident’s room for the resident to self-administer, stating the resident preferred not to be supervised when taking pills. The DON later confirmed that no residents in the facility were authorized to self-administer medications and that this resident, given her severe cognitive impairment, would not be appropriate for self-administration, and that nursing staff were required to remain with residents until all medications were taken.