Improper Security and Storage of Controlled Medications Awaiting Destruction
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of drugs and biologicals, specifically related to the medication destruction closet and narcotic safe. Observations on 2/23/2026 at 9:10 a.m. showed the ADON’s office door open with no staff present, while the medication destruction closet inside that office had a locked padlock and door handle but an unlocked deadbolt. Inside the closet, a safe containing narcotic medications awaiting destruction was present but was not permanently affixed and could be picked up and moved. Later that day at 12:24 p.m., the DON unlocked the padlock and door handle, opened the narcotic safe, and demonstrated that the safe could be tilted forward, confirming it was not permanently secured to the shelf. During interview, the ADON reported she had been trained by the previous ADON for about one week and understood only that medications were supposed to be in the closet locked; she did not know they were required to be in a locked safe that was permanently affixed to the shelf. Review of facility policies showed that only authorized licensed nursing and/or pharmacy personnel were to have access to controlled drugs, that controlled substances were to be stored in a locked container separate from non-controlled medications, and that all unused controlled substances were to be retained in a securely locked area with restricted access until disposal. Another policy specified that controlled substances and other drugs subject to abuse must be separately locked in permanently affixed compartments. The facility failed to ensure these requirements were met for the medication destruction closet and narcotic safe between 12/04/2025 and 1/15/2026, and the report states this failure could put residents at risk of unauthorized use of medication and accidental ingestions or use of unprescribed medication.
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