Unsecured Controlled Medications Allowed Resident Access and Overdose
Summary
The deficiency involves the facility’s failure to secure medications and keep them inaccessible to residents. Pharmacy records showed that a delivery including three bags of medications (one white, one blue, and one red) arrived in the evening, with the red bag containing 90 tablets of alprazolam and 90 tablets of lorazepam. Licensed Nurse G signed for the medications, placed the bags on a chair in the nurse’s station, and left them there without securing them in a locked compartment. Video footage later confirmed that the nurse’s station was left unattended with the medication bags still present on the chair. While the nurse’s station was unmanned, two residents were observed outside the area. One resident entered the unsupervised, unsecured nurse’s station, took drinking cups and other items, and then, at the direction of the other resident, took the red bag of medications from the chair and left the nurse’s station. The resident who directed this action later took the red bag back to his room. At an unknown time, he ingested 14 tablets of alprazolam and 18 tablets of lorazepam. Subsequent discovery of pill cards hidden in a paper towel dispenser showed that some of the alprazolam and lorazepam tablets remained, but a portion of each medication was missing, consistent with the amounts the resident reported taking. The resident who ingested the medications had documented diagnoses of schizophrenia, anxiety, suicidal ideation, and major depressive disorder, with a recent MDS indicating intact cognition but severe depression, hallucinations, delusions, and rejection of care. His care plan documented trauma-related distress, hallucinations, substance use that exacerbated suicidal thoughts, and intermittent passive suicidal ideation, with directions for staff to assess for suicidal ideation, intent, and plan each shift, especially at night. In the early morning hours after the ingestion, nursing notes documented that the resident was lethargic, staggering, had slurred speech, and then experienced repeated episodes of dark vomiting, short labored breaths, incoherent speech, and lethargic behavior, leading to transfer to the hospital where he was intubated and later diagnosed with pneumonia and fever secondary to suspected aspiration of fluid into his lungs. The facility’s own policies required that all drugs and biologicals be stored in a safe, secure manner and that resident safety, supervision, and assistance to prevent accidents be a facility-wide priority, but the medications were not secured and the nurse’s station was left unattended, allowing residents access to controlled substances. Further documentation and witness statements highlighted conflicting accounts regarding who was responsible for putting away the delivered medications. LN G stated he had set the medications aside on the overflow medication cart to be put away later and that a Certified Medication Aide later put them away, while the CMA stated she never received a handoff of medications from LN G and only found and stored the white and blue bags, not any controlled substances or a red bag. The facility’s incident report and administrative review confirmed that the controlled substances for two other residents were missing from the medication supply, that the pharmacy delivery forms and controlled substance count sheets could not initially be located, and that the missing narcotics were later found hidden in a paper towel dispenser in a resident’s room. Subsequent observation by the surveyor also showed that the nurse’s station could be accessed by reaching over and unbolting the inside barrel bolt lock, and that a resident was present at the counter while the station was unattended, further demonstrating that medications and staff work areas were not consistently secured from resident access.
Removal Plan
- Re-education on narcotic safekeeping to prevent diversions
- Provision of adequate resident supervision to ensure safety
- Termination of LN G from employment
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unattended medications were found left at a resident’s bedside, on another resident’s bedside table, and in a dining room where a resident was eating breakfast, even though staff confirmed the residents were not able to self-administer. An LPN also found expired ophthalmic drops in a medication cart, and the DON confirmed the eye drops were expired and should have been discarded.
Medication refrigerator temperatures were not kept within the required range and were not checked consistently. The main med refrigerator was found above range, with missing temperature logs across multiple months. It stored several residents’ insulins and other meds/biologicals, and an LPN later found the unit at about 50 degrees F. The DON stated staff should check refrigerator temperatures daily, and the consultant pharmacist reviewed how long the stored items could remain usable once the safe range was exceeded.
Medication labeling was deficient in the 500 wing med cart. An LPN observed a Lantus insulin pen with no expiration date and two bottles of Systane eye drops with missing opened-on and/or expiration dates; the LPN stated the cart lacked the stickers needed for proper labeling. The DON stated staff were expected to label items such as eye drops, insulin, nasal sprays, and inhalers with opened-on and expires-on dates when medications were checked in from pharmacy.
Unsecured Medication Cart and Expired Medications: An unlocked, unattended med cart was observed in a nursing station with open access, and expired Vitamin B-12 was found on another cart. An MA stated she administered the expired medication without checking the expiration date, while the DON said staff were expected to verify expiration dates and keep med carts locked when unattended.
Medications were left unsecured on medication carts and one cart was observed unlocked and unattended. An RN left an opened antibiotic for a resident on top of a cart, another RN left Polyethylene Glycol and Fluticasone nasal spray on top of a cart while administering meds, and a CMA was observed with an unlocked cart whose drawers were easily opened. The DON stated medications should be locked in the cart and refrigerated meds returned to the refrigerator after use.
An opened vial of Tubersol PPD in the First Floor Main Medication Room refrigerator was found without an open date, and staff could not determine its expiration date. Facility policy required stock medication labels to include the expiration date when applicable, and the ADON confirmed the vial was not dated.
Unattended Medications and Expired Eye Drops Found
Penalty
Summary
Drugs and biologicals were not stored and handled in accordance with accepted professional principles when unattended medications were left at the bedside and in a dining room, and expired medication was found in a medication cart. During observation, a clear medication cup containing a white cream was found behind a picture frame on a nightstand in a resident’s room, and the resident stated nurses apply the cream to the groin area. Staff confirmed the resident was not able to self-administer medication. In another room, a medication cup with two white tablets was left on the bedside table for a resident who was also not able to self-administer medication, and the RN confirmed the medication had been left unattended at bedside. In the memory care dining room, a resident was observed eating breakfast with a medication cup containing five tablets on the table while the nurse stood away from the residents at the medication cart. The LPN later confirmed the resident still had medication in the cup, and the DON stated medications are to be administered with the staff staying with the resident to ensure they are consumed. In addition, an observation of a hallway medication cart found two expired bottles of Brimonidine Tartrate Ophthalmic Solution 0.2% and one expired bottle of Olopatadine Hydrochloride Ophthalmic Solution. Staff stated expired eye drops should be discarded, and the DON confirmed the eye drops were expired and should have been disposed of and reordered.
Medication Refrigerator Temperatures Not Monitored Consistently
Penalty
Summary
The facility failed to keep medication refrigerators within the recommended temperature range for 1 of 2 medication refrigerators. During observation, the main medication storage room refrigerator read 42 degrees F, while the temperature log for July showed the last recorded reading was 39 degrees F. The log had no entries for July 1, 2, 3, 4, or 6, and staff were using food refrigerator temperature logs. The temperature log identified a safe range of 32 to 41 degrees F, and instructions directed staff to report any out-of-range temperature to the supervisor. The LPN verified that the July temperature had been recorded only one time. Review of prior months showed the same issue with incomplete monitoring: June had only four recorded temperatures with 26 days missing, May had no temperature readings available, and April had three recorded temperatures with 28 days missing. The refrigerator contained medications and biologicals including multiple residents’ insulins such as Lantus, NovoLog, Humalog, and Basaglar, as well as Trulicity, calcitonin spray, Evenity, Aplisol, Engerix B, and Comirnaty. The DON stated staff should check refrigerator temperatures daily, and an LPN later found the refrigerator temperature was about 50 degrees F and moved the medications to a different refrigerator. The consultant pharmacist reviewed the medications and identified varying time limits for use once the refrigerator exceeded the safe range, based on the last known temperature reading.
Medication Labeling Deficiency in 500 Wing Cart
Penalty
Summary
Medications and biologicals in the facility were not labeled in accordance with accepted professional principles in the 500 wing medication cart. During observation with an LPN, one Lantus insulin pen was found with no expiration date noted. A box containing two bottles of Systane eye drops was also observed; one bottle had an open date but no expiration date, and the second bottle had neither an opened-on date nor an expiration date. The LPN stated that when medications were received, staff were supposed to place an opened-on/expired sticker on the medication and write the date it was first used and the expiration date on the sticker, but no stickers could be found in the cart during the demonstration. The LPN stated that without an opened-on or expiration date, staff would not know how long a medication had been opened or whether it was safe to use. The LPN also stated that eye drops expire 28 days after opening, and the eye drops dated [DATE] were past expiration. During interview, the DON stated she expected staff to place opened-on and expires-on stickers on medications such as eye drops, insulin, nasal sprays, and inhalers when medications were checked in from pharmacy, and that this information was important to ensure the medication was safe to use and still within its therapeutic level. A policy related to medication labeling and storage was requested but not provided.
Unsecured Medication Cart and Expired Medications
Penalty
Summary
Drugs and biologicals were not stored and handled in accordance with accepted professional principles when an unattended medication cart was found unlocked in the C and D Hall nursing station and expired medications were found on the A Hall medication cart. During observation, the C Hall medication cart was left unlocked and unattended inside a nursing station that had two accessible entrances, including one open entrance with no door. The Director of Nursing Services stated the cart should be locked when unattended, and Nurse #1 stated she had locked the cart after handoff but was unsure why it was unlocked and said she was the only person with a key. On the A Hall medication cart, a bottle of Vitamin B-12 500 mcg with an expiration date of 1/2026 was available for use, and Medication Aide #1 stated she had administered it to a resident without checking the expiration date. A second bottle of Vitamin B-12 1000 mcg with an expiration date of 6/2026 was also observed on the cart. The DON stated nurses or MAs were expected to check expiration dates before administering medications and to remove expired medications from carts at the start of each shift, and the Administrator stated expired medications should be removed from medication carts and replaced with non-expired medications.
Unsecured medications left on carts and an unlocked medication cart observed
Penalty
Summary
Medications were not securely stored in three observed medication carts. On 6/30/26, an opened bottle of liquid Amoxicillin-Pot Clavulanate oral suspension for resident 181 was left on top of a medication cart in the 700 hallway outside resident 75's room with no staff present. During the time it remained there, CMA X, an activities assistant, and two unidentified visitors walked past the cart. Clinical care leader S later removed the antibiotic and stated RN V had been assigned to that cart and had left the medication there; RN V acknowledged she had forgotten to return the antibiotic to the refrigerator after leaving the cart. Resident 181 had a physician's order for Amoxicillin-Pot Clavulanate oral suspension via NG tube for acute cystitis without hematuria. On 7/1/26, RN FF was observed preparing medications for residents 47 and 150 and left a bottle of Polyethylene Glycol and a bottle of Fluticasone nasal spray on top of the medication cart while she walked into the dining room to administer medications. RN FF stated she left the Fluticasone nasal spray there so she would not forget to give it to resident 89, who was eating, and said the Polyethylene Glycol bottle was not supposed to be left unsecured. On 7/2/26, RN/clinical nurse leader I and CMA Z were observed with an unlocked medication cart in the 200 hallway with no nurse or medication aide attending it, and the drawers were easily opened. CMA Z stated she thought she had locked the cart. The DON stated medications were expected to be locked in the cart and not left unattended, and refrigerated medications were expected to be returned to the refrigerator after use.
Opened Tubersol Vial Lacked Required Date
Penalty
Summary
Medications were not properly dated when opened in the First Floor Main Medication Room. Review of the facility policy on labeling medication containers stated that stock medication labels must include the expiration date when applicable. Manufacturer guidance for Tubersol PPD stated that vials entered and in use for 30 days should be discarded. During observation of the First Floor Main Medication Room refrigerator, an opened vial of Tubersol was found without an open date, so staff could not determine the expiration date. The Assistant Director of Nursing confirmed that the opened vial lacked an open date.
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