F0761

E

Unsecured and Undestroyed Controlled Substances Left on DON’s Desk

Cincinnati, Ohio Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s handling of controlled substances when multiple unsecured narcotic medications were observed lying on the DON’s desk during an interview with the DON and the Regional Clinical Director. The medications included lorazepam oral concentrate and morphine sulfate oral solution prescribed for one resident who still resided in the facility, with significant amounts remaining in the bottles, as well as multiple bottles of morphine sulfate and lorazepam concentrate for several residents who had been discharged. The DON confirmed that these controlled medications were unsecured and acknowledged that controlled substances should be stored in a permanently affixed, locked compartment.

The facility’s written policies titled “Controlled Substances” and “Discarding and Destroying Medications” required that controlled substances be separately locked in permanently affixed compartments and that any remaining controlled substances after discharge or discontinuation be securely locked in an area with restricted access until destruction, with disposal to occur immediately and no longer than three days after discontinuation. Contrary to these policies, the controlled medications for discharged residents were kept on the DON’s desk rather than in a securely locked area, and the DON stated she was behind in destroying the controlled substances. This failure to secure and timely destroy controlled substances affected four identified residents and had the potential to affect 56 independently mobile residents in a facility census of 70.