F0761

D

Unlocked Treatment Cart and Improper Storage of Wound Cleanser

Gilmer, Texas Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to medication storage and security involving a treatment cart on Hall A. During an observation at 10:46 a.m., the treatment cart was found unlocked and unattended, with a wound cleanser bottle sitting on top of the cart. The cart could be opened by the surveyor, and prescription triamcinolone cream tubes were found in the top drawer. Residents and staff were observed in the vicinity of the unlocked cart, and no staff noticed or intervened when the surveyor opened it. The facility’s written policy on medication storage stated that medications and biologicals are to be stored safely, securely, and properly, accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that potentially harmful substances must be clearly identified and stored in a locked area separate from medications.

In interviews, the Treatment Nurse stated she usually locked the treatment cart because it contained items and some medications, including wound cleanser and creams, that could be potentially dangerous if ingested by a resident. She reported that she had stepped into the shower room to assist an aide with a resident and did not take the time to put the wound cleanser away or lock the treatment cart before leaving it unattended. The Administrator stated she expected the Treatment Nurse to keep the treatment cart locked at all times to prevent accidents such as a resident drinking or spraying a harmful substance into their eyes. The DON stated she expected the treatment cart to be either under the direct supervision of the Treatment Nurse or locked at all times and reported that she conducted daily walks through the facility to check that medication and treatment carts remained locked.