Unlocked and Unattended Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to secure multiple medication carts in accordance with its own Medication Storage policy and accepted professional standards. The policy dated 12/11/25 requires that all drugs and biologicals be stored in locked compartments, including medication carts, and specifies that during a medication pass, medications must either be under the direct observation of the person administering them or locked in the cart. Surveyors observed that these requirements were not followed for three of four medication carts. On one observation, the Vineyard and Rosewood medication carts were found sitting in the hallway next to each other, both unlocked and unattended. An LPN confirmed that the Vineyard cart was unlocked and unattended, and an RN confirmed the same for the Rosewood cart, acknowledging that the facility failed to properly secure the carts while not in use. On another observation, the Rosewood 2 medication cart was also seen in the hallway, unlocked and unattended, while the responsible RN reported being in a resident room at the time and confirmed the cart was not secured. The Nursing Home Administrator later confirmed that the facility failed to properly secure three of four medication carts (Vineyard, Rosewood, and Rosewood 2), as required by facility policy and applicable state regulations.
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