F0761

E

Unsecured Medications in Resident Rooms and on Medication Cart

Phoenix, Arizona Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure medications were securely stored and not left unattended at residents’ bedsides or on top of the medication cart. For one resident with chronic obstructive pulmonary disease, atrial fibrillation, and pneumonia, surveyors observed a prescribed Breztri inhaler and a tube of Voltaren gel on the resident’s vanity sink area, and an albuterol inhaler at the bedside. The resident stated that the nurse must have forgotten to take the Breztri inhaler and Voltaren gel and that the inhaler stays on the bedside table in case it is needed. A registered nurse confirmed that the resident only had a physician’s order for self-administration of a Ventolin rescue inhaler and did not have a current order for self-administration of the Breztri inhaler or Voltaren gel, and acknowledged that medications should not be left at the bedside.

A second resident, admitted with chronic obstructive pulmonary disease, abdominal aortic aneurysm without rupture, unsteadiness on feet, difficulty in walking, and generalized muscle weakness, was found to have two Lidocaine roll-on bottles on the vanity sink area. This resident, who had intact cognition per the MDS, reported bringing the Lidocaine roll-ons at admission, keeping them at the sink, and using them since admission. The resident also stated that staff had applied the Lidocaine to the hip for pain but could not recall which staff had done so. Review of provider orders and the care plan showed no evidence of prescribed Lidocaine roll-ons or care plan interventions for their use, although the care plan did include a focus on left hip pain with interventions for pain medications as ordered.

In addition to unsecured medications in resident rooms, surveyors observed a medication security lapse during a medication pass. An LPN removed metronidazole 500 mg from the medication cart, placed it in a medication cup, and left the cup unattended on top of the medication cart while walking down the hall toward a resident’s room with her back to the cart. No residents were observed passing the cart at that time. In subsequent interviews, the LPN acknowledged that leaving medications unattended created a risk that someone could access medications that were not theirs, and the DON confirmed that the facility’s expectation is that no medications should be left unattended and that medications should be stored in a safe place or taken with the nurse when stepping away. Facility policies reviewed by surveyors stated that medications are to be administered safely and appropriately per physician order and that residents requesting to self-administer medications must be assessed by the interdisciplinary team to determine if self-administration is safe.

Interviews with nursing staff and the DON further described the facility’s stated processes and expectations for self-administration of medications, including assessing residents for safety and cognitive ability, obtaining provider orders, documenting self-administration on the MAR, and implementing safety measures to prevent other residents from accessing medications in resident rooms. Staff also described that over-the-counter products such as Tylenol, stool softeners, and Lidocaine roll-ons are considered medications and identified risks associated with medications being left at the bedside or otherwise unsecured. Despite these stated processes and expectations, the observations of unsecured prescribed medications in one resident’s room, non-prescribed Lidocaine roll-ons in another resident’s room, and unattended medication on top of the medication cart demonstrate that medications were not consistently stored in locked compartments or otherwise kept secure as required by facility policy and professional standards.