Improper Storage and Labeling of OTC Medications in Medication Carts and Central Supply
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were properly labeled and securely stored in accordance with facility policy and accepted professional standards. Facility policies required that all medications in carts, medication rooms, or central supply be locked at all times unless in use or under the direct observation of the medication nurse, and that nursing staff check medication labels and expiration dates prior to administration. Policies also required that opened multi-dose containers be dated when opened and that the label of all medications be checked against the physician’s order before removal from the container. Additionally, the facility’s procedure for unavailable medications required staff to obtain OTC medications from central supply when not available in the cart and to notify nurse management if a system-wide issue was identified. Surveyors found that OTC medications in central supply were stored in closed, factory-labeled bottles on open shelves in a room accessed by a keypad lock. The Central Supply Manager stated that staff had access to the room via a code, but she was not aware of all staff who had the code, and reported that therapists and nurse aides, in addition to nursing staff, had collected materials from central supply after hours. This meant that OTC medications were not stored in locked compartments accessible only to authorized personnel, contrary to the facility’s own policy and accepted standards for medication security. On six of ten nursing units (1C, 1D, 3C, 3D, 3F, and 4F), surveyors observed OTC medications stored in open plastic cups with handwritten labels inside medication carts, rather than in their original, labeled bottles. On unit 1C, one cart contained seven cups labeled with drug names such as an eye supplement, guaifenesin ER 600 mg, melatonin 5 mg, cetirizine 10 mg, iron, B12 100, and Fiber Con, but the LPN could not determine doses, manufacture dates, expiration dates, or when the original containers had been opened. Another cart on the same unit contained cups labeled with ASA EC, Mucinex, Ibuprofen 200 mg, and a cup labeled Senna 8.6 that contained a mixture of red, pink, and brown pills, some of which the LPN could not identify. Residents on this unit had physician orders that correlated with the medications stored in these cups. On unit 1D, a medication cart contained seven cups labeled with various supplements and medications, including Oyster Shell D3, Cranberry 450, Vit D 2000 iu, omep 2D, MVI, cetirizine, and vit D3 2000 iu. The LPN on this unit was unable to determine doses, manufacture dates, expiration dates, or when the original containers had been opened, even though residents on the unit had orders corresponding to these medications. On unit 3C, a cart contained cups labeled Vitamin D3 50,000 iu, Docusate, and Vit C 500 mg, and the LPN again could not determine doses, manufacture dates, expiration dates, or when the original containers had been opened, despite residents having corresponding physician orders. On unit 3D, a medication cart contained cups labeled Senna 8.6 mg, Vitamin D3 50,000, Multivitamin, and Fiber-lax, and the LPN could not determine manufacture dates, expiration dates, or when the original containers had been opened, while residents on the unit had orders matching these medications. On unit 3F, one cart contained cups labeled Vit D 2,000 iu and Tylenol 500, and another cup labeled Iron 325 that contained white and black pills, some of which the LPN could not identify or trace back to an original container. A second cart on 3F contained cups labeled Calcium 600+D 10 mcg and Iron 325, with the LPN again unable to determine manufacture dates, expiration dates, or opening dates of the original containers, even though residents had corresponding orders. On unit 4F, one medication cart contained 14 cups labeled with various medications and supplements, including Docusate Sodium, Ibuprofen, Oyster Calcium, Iron, Multi vitamins, Cranberry, Mag Ox, Aspirin, ASA 81, Docusate, Multivit, Therems, Fe sulp, and Oyster Cple. Another cart on the same unit contained two unlabeled cups with pills and ten cups with handwritten labels such as Vit B12, Cranberry, Ibuprofen, Iron, Aspirin, Multivit, Oyster Cal, Thera-M, VitD, and Certizine. The LPN on this unit was unable to determine doses, manufacture dates, expiration dates, or when the original containers had been opened, and could not identify the pills in the two unlabeled cups, even though residents on the unit had physician orders that correlated with the medications in these cups. The DON confirmed that OTC medications were improperly stored and labeled in open, hand-labeled cups in the medication carts. The surveyors determined that this failure to properly store and label medications put residents at risk for medication administration errors and resulted in an Immediate Jeopardy situation at F761-K.
Removal Plan
- Discard and destroy all medications observed in medication cups or unlabeled cups, or any medication that is unable to be identified.
- Replace any discarded medication with an unopened, labeled OTC medication bottle.
- Store OTC medications in the original, labeled bottle in the medication carts and administer to residents following medication administration policies.
- Submit OTC medication orders with the Clinical Supply order and purchase needed OTC medications from a local pharmacy if not sent, backordered, or out of stock.
- Change the Central Supply keylock code and provide it only to central supply staff and RN Supervisors.
- Train all licensed and central supply staff regarding storage of medications, proper distribution of OTC medications, and the medication not available procedure.
- Audit all medication carts to ensure no loose or unlabeled medications are stored in any cart.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unattended medications were found left at a resident’s bedside, on another resident’s bedside table, and in a dining room where a resident was eating breakfast, even though staff confirmed the residents were not able to self-administer. An LPN also found expired ophthalmic drops in a medication cart, and the DON confirmed the eye drops were expired and should have been discarded.
Medication refrigerator temperatures were not kept within the required range and were not checked consistently. The main med refrigerator was found above range, with missing temperature logs across multiple months. It stored several residents’ insulins and other meds/biologicals, and an LPN later found the unit at about 50 degrees F. The DON stated staff should check refrigerator temperatures daily, and the consultant pharmacist reviewed how long the stored items could remain usable once the safe range was exceeded.
Medication labeling was deficient in the 500 wing med cart. An LPN observed a Lantus insulin pen with no expiration date and two bottles of Systane eye drops with missing opened-on and/or expiration dates; the LPN stated the cart lacked the stickers needed for proper labeling. The DON stated staff were expected to label items such as eye drops, insulin, nasal sprays, and inhalers with opened-on and expires-on dates when medications were checked in from pharmacy.
Unsecured Medication Cart and Expired Medications: An unlocked, unattended med cart was observed in a nursing station with open access, and expired Vitamin B-12 was found on another cart. An MA stated she administered the expired medication without checking the expiration date, while the DON said staff were expected to verify expiration dates and keep med carts locked when unattended.
Medications were left unsecured on medication carts and one cart was observed unlocked and unattended. An RN left an opened antibiotic for a resident on top of a cart, another RN left Polyethylene Glycol and Fluticasone nasal spray on top of a cart while administering meds, and a CMA was observed with an unlocked cart whose drawers were easily opened. The DON stated medications should be locked in the cart and refrigerated meds returned to the refrigerator after use.
An opened vial of Tubersol PPD in the First Floor Main Medication Room refrigerator was found without an open date, and staff could not determine its expiration date. Facility policy required stock medication labels to include the expiration date when applicable, and the ADON confirmed the vial was not dated.
Unattended Medications and Expired Eye Drops Found
Penalty
Summary
Drugs and biologicals were not stored and handled in accordance with accepted professional principles when unattended medications were left at the bedside and in a dining room, and expired medication was found in a medication cart. During observation, a clear medication cup containing a white cream was found behind a picture frame on a nightstand in a resident’s room, and the resident stated nurses apply the cream to the groin area. Staff confirmed the resident was not able to self-administer medication. In another room, a medication cup with two white tablets was left on the bedside table for a resident who was also not able to self-administer medication, and the RN confirmed the medication had been left unattended at bedside. In the memory care dining room, a resident was observed eating breakfast with a medication cup containing five tablets on the table while the nurse stood away from the residents at the medication cart. The LPN later confirmed the resident still had medication in the cup, and the DON stated medications are to be administered with the staff staying with the resident to ensure they are consumed. In addition, an observation of a hallway medication cart found two expired bottles of Brimonidine Tartrate Ophthalmic Solution 0.2% and one expired bottle of Olopatadine Hydrochloride Ophthalmic Solution. Staff stated expired eye drops should be discarded, and the DON confirmed the eye drops were expired and should have been disposed of and reordered.
Medication Refrigerator Temperatures Not Monitored Consistently
Penalty
Summary
The facility failed to keep medication refrigerators within the recommended temperature range for 1 of 2 medication refrigerators. During observation, the main medication storage room refrigerator read 42 degrees F, while the temperature log for July showed the last recorded reading was 39 degrees F. The log had no entries for July 1, 2, 3, 4, or 6, and staff were using food refrigerator temperature logs. The temperature log identified a safe range of 32 to 41 degrees F, and instructions directed staff to report any out-of-range temperature to the supervisor. The LPN verified that the July temperature had been recorded only one time. Review of prior months showed the same issue with incomplete monitoring: June had only four recorded temperatures with 26 days missing, May had no temperature readings available, and April had three recorded temperatures with 28 days missing. The refrigerator contained medications and biologicals including multiple residents’ insulins such as Lantus, NovoLog, Humalog, and Basaglar, as well as Trulicity, calcitonin spray, Evenity, Aplisol, Engerix B, and Comirnaty. The DON stated staff should check refrigerator temperatures daily, and an LPN later found the refrigerator temperature was about 50 degrees F and moved the medications to a different refrigerator. The consultant pharmacist reviewed the medications and identified varying time limits for use once the refrigerator exceeded the safe range, based on the last known temperature reading.
Medication Labeling Deficiency in 500 Wing Cart
Penalty
Summary
Medications and biologicals in the facility were not labeled in accordance with accepted professional principles in the 500 wing medication cart. During observation with an LPN, one Lantus insulin pen was found with no expiration date noted. A box containing two bottles of Systane eye drops was also observed; one bottle had an open date but no expiration date, and the second bottle had neither an opened-on date nor an expiration date. The LPN stated that when medications were received, staff were supposed to place an opened-on/expired sticker on the medication and write the date it was first used and the expiration date on the sticker, but no stickers could be found in the cart during the demonstration. The LPN stated that without an opened-on or expiration date, staff would not know how long a medication had been opened or whether it was safe to use. The LPN also stated that eye drops expire 28 days after opening, and the eye drops dated [DATE] were past expiration. During interview, the DON stated she expected staff to place opened-on and expires-on stickers on medications such as eye drops, insulin, nasal sprays, and inhalers when medications were checked in from pharmacy, and that this information was important to ensure the medication was safe to use and still within its therapeutic level. A policy related to medication labeling and storage was requested but not provided.
Unsecured Medication Cart and Expired Medications
Penalty
Summary
Drugs and biologicals were not stored and handled in accordance with accepted professional principles when an unattended medication cart was found unlocked in the C and D Hall nursing station and expired medications were found on the A Hall medication cart. During observation, the C Hall medication cart was left unlocked and unattended inside a nursing station that had two accessible entrances, including one open entrance with no door. The Director of Nursing Services stated the cart should be locked when unattended, and Nurse #1 stated she had locked the cart after handoff but was unsure why it was unlocked and said she was the only person with a key. On the A Hall medication cart, a bottle of Vitamin B-12 500 mcg with an expiration date of 1/2026 was available for use, and Medication Aide #1 stated she had administered it to a resident without checking the expiration date. A second bottle of Vitamin B-12 1000 mcg with an expiration date of 6/2026 was also observed on the cart. The DON stated nurses or MAs were expected to check expiration dates before administering medications and to remove expired medications from carts at the start of each shift, and the Administrator stated expired medications should be removed from medication carts and replaced with non-expired medications.
Unsecured medications left on carts and an unlocked medication cart observed
Penalty
Summary
Medications were not securely stored in three observed medication carts. On 6/30/26, an opened bottle of liquid Amoxicillin-Pot Clavulanate oral suspension for resident 181 was left on top of a medication cart in the 700 hallway outside resident 75's room with no staff present. During the time it remained there, CMA X, an activities assistant, and two unidentified visitors walked past the cart. Clinical care leader S later removed the antibiotic and stated RN V had been assigned to that cart and had left the medication there; RN V acknowledged she had forgotten to return the antibiotic to the refrigerator after leaving the cart. Resident 181 had a physician's order for Amoxicillin-Pot Clavulanate oral suspension via NG tube for acute cystitis without hematuria. On 7/1/26, RN FF was observed preparing medications for residents 47 and 150 and left a bottle of Polyethylene Glycol and a bottle of Fluticasone nasal spray on top of the medication cart while she walked into the dining room to administer medications. RN FF stated she left the Fluticasone nasal spray there so she would not forget to give it to resident 89, who was eating, and said the Polyethylene Glycol bottle was not supposed to be left unsecured. On 7/2/26, RN/clinical nurse leader I and CMA Z were observed with an unlocked medication cart in the 200 hallway with no nurse or medication aide attending it, and the drawers were easily opened. CMA Z stated she thought she had locked the cart. The DON stated medications were expected to be locked in the cart and not left unattended, and refrigerated medications were expected to be returned to the refrigerator after use.
Opened Tubersol Vial Lacked Required Date
Penalty
Summary
Medications were not properly dated when opened in the First Floor Main Medication Room. Review of the facility policy on labeling medication containers stated that stock medication labels must include the expiration date when applicable. Manufacturer guidance for Tubersol PPD stated that vials entered and in use for 30 days should be discarded. During observation of the First Floor Main Medication Room refrigerator, an opened vial of Tubersol was found without an open date, so staff could not determine the expiration date. The Assistant Director of Nursing confirmed that the opened vial lacked an open date.
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