Medications Left Unsecured in Resident Rooms
Penalty
Summary
The facility failed to ensure medications were stored safely and securely in accordance with its policy and regulatory requirements. The facility’s policy on centralized medication storage, revised 8/2024, stated that medications are to be stored safely, securely, and properly, accessible only to authorized personnel. During an observation on 3/17/26 at 8:14 AM, surveyors found a container of Gavilyte-G solution, labeled by the pharmacy for Resident 3, sitting on the bathroom sink in Resident 3’s bathroom with approximately one inch of solution remaining. In an interview on 3/16/26 at 10:47 AM, the Wound and Infection Nurse confirmed that the Gavilyte-G container should not have been stored on the resident’s bathroom sink. The facility also failed to secure multiple medications in the room of Resident 2. Resident 2’s MDS dated 01-04-2026 showed the resident was admitted on a prior date, had a BIMS score of 13 indicating cognitive intactness, required extensive assistance with toileting, bathing, dressing, hygiene, bed mobility, and transfers, was at risk of developing a pressure ulcer, and had two venous ulcers. On 03-16-2026, an observation revealed a clear plastic bag containing medications, including furosemide, pantoprazole, carvedilol, Entresto, aspirin, and a Lantus insulin pen, sitting on the dresser in Resident 2’s room. In an interview on the same date, LPN D confirmed that these medications were on the dresser and acknowledged that medications are supposed to be kept locked up.
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