F0761

E

Unlocked and Unattended Medication Cart Accessible to Cognitively Impaired Residents

Wintersville, Ohio Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The facility failed to ensure medications were stored to prevent access by unauthorized persons when a medication cart was left unlocked and unattended. During a tour on 02/05/26 at 7:52 A.M., an RN walked away from her medication cart, entered a resident room down the hall, and moved out of sight of the cart, leaving it unlocked. At 7:54 A.M., the RN returned to the cart and confirmed she had left it unlocked and unattended. The facility had identified 23 residents as cognitively impaired and independently mobile, and the unlocked cart was accessible in this environment.

Review of the facility’s January 2025 Storage of Medication policy showed that only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications were allowed access to medication carts, and that medication rooms, cabinets, and medication supplies should remain locked when not in use or when not attended by authorized personnel. The observed practice of leaving the medication cart unlocked and unattended was inconsistent with this policy and formed the basis of the cited deficiency, which was investigated under Complaint Number 2734445.