Unsecured, Unidentified Medication Found Outside Resident Room
Penalty
Summary
Surveyors identified a deficiency in medication storage and control when, during an onsite investigation on January 29, 2026, at approximately 10:15 a.m., they observed an unidentified pill on the floor outside the entrance of Resident R6’s room. The pill was not labeled, packaged, or stored in a secure medication container, contrary to the facility’s January 2025 medication storage policy, which requires medications to remain in pharmacy-dispensed containers that meet state and federal labeling requirements and to be stored in controlled environments such as medication carts, rooms, or cabinets. In an interview at 12:20 p.m., licensed employee E13 stated that staff were unable to identify the pill or determine which resident, if any, it had been prescribed to. In a subsequent interview at approximately 12:33 p.m., the Director of Nursing confirmed that medications are required to be secured at all times and acknowledged that an unidentified pill found outside a resident room posed a risk for unintended ingestion. The facility was found to have failed to ensure medications were properly controlled and secured in accordance with its policy and regulatory requirements.
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