F0761

E

Improper Labeling and Storage of Insulin and Other Medications on Multiple Medication Carts

Ocala, Florida Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that drugs and biologicals, particularly insulin and ophthalmic solutions, were properly labeled, stored, and maintained in accordance with professional standards and facility policy. During observation of medication cart #1 with an RN, surveyors found two unlabeled medication cups containing multiple tablets, as well as several insulin vials that were either opened without a date or expired, and multiple unopened insulin vials labeled by the pharmacy to be refrigerated until opened but stored on the cart instead. The RN acknowledged that medications should not be unlabeled, should not be pre-poured and left on the cart, and that insulin requiring refrigeration should not be kept on the cart and that expired insulin should not be present.

On medication cart #2, observed with an LPN, surveyors identified an unopened Lispro insulin that should have been refrigerated until opened and multiple Latanoprost and Timolol ophthalmic solutions that were either missing open dates or expiration dates, with the LPN stating that all medicines should be in the refrigerator if required, labeled with open dates, and removed if expired, and acknowledging that the eye drops were expired. On medication cart #4, another LPN was observed with Lantus and Novolin insulin vials that lacked open dates or expiration dates, along with an unopened Lantus insulin that should have been refrigerated until opened; the LPN stated that all medications should have open or expiration dates and remain refrigerated until needed. On medication cart #5, surveyors found multiple unopened insulin vials labeled to be refrigerated until opened stored on the cart, an opened Lantus insulin without pharmacy packaging or resident identification and without open or expiration dates, an opened Aspart insulin without dates, and two expired insulin vials with documented open dates; the LPN confirmed there should not be expired medicines on the cart and that insulins should be labeled and refrigerated when not in use.

Further observations on medication carts #6 and #7 revealed additional issues with insulin storage and labeling. On cart #6, there were unopened Aspart and Lantus insulin vials labeled to be refrigerated until opened and an opened Lispro insulin without an open date or expiration date; the LPN stated that every insulin should have an open or expiration date and that unused insulin should remain in the refrigerator. On cart #7, surveyors found an expired Lispro insulin with an open date, unopened Glargine and Humulin insulins that were labeled to be refrigerated until opened but stored on the cart, and an opened Novolin insulin without an open date or expiration date; the LPN stated that every insulin needs expiration dates and unopened insulins should stay in the refrigerator. Review of facility policies confirmed that medications are required to be stored in original labeled containers, under proper conditions per manufacturer instructions, with expired or discontinued medications removed, and that medications requiring refrigeration must be stored at 2–8°C (36–46°F).