F0761

D

Improper Storage and Labeling of Medications on Medication Cart

East Providence, Rhode Island Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to store and label medications according to professional standards and the facility’s own Medication Administration Safety Program (MASP) policy on one of three medication carts reviewed. The policy requires periodic checks for expired medications, prohibits altering labels except to note the date opened, and mandates that inhalers be labeled and stored per manufacturer guidelines. During observation of the first-floor CMT medication cart with the CMT present, surveyors found a Wixela inhalation device out of its foil package with a dose counter of 57 that was not labeled with the date it was opened, and another Wixela device out of its foil pouch with a dose counter of 5 that was labeled as opened on 10/23/2025, despite manufacturer guidance that the device should be discarded one month after removal from the foil pouch or when the dose counter reaches zero. A fluticasone propionate inhalation device was also found out of its foil pouch with a dose counter of 45 and labeled as opened on 10/23/2025, even though manufacturer guidance states it should be discarded two months after opening the foil pouch or when the dose counter reaches zero.

Additionally, surveyors observed one opened bottle of Allergy Relief (fexofenadine hydrochloride 180 mg) on the cart that lacked a visible expiration date. The CMT acknowledged these findings and stated that the Allergy Relief was house stock and that a resident was currently prescribed this medication. In a subsequent interview, the DON was unable to provide evidence that the facility stored and labeled drugs in accordance with the facility’s policy and accepted professional principles, confirming the deficiency in medication storage and labeling practices on the reviewed medication cart.