Improper Pre-Pouring and Storage of Medications in Medication Cart
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely stored and administered in accordance with facility policy and professional standards. The facility’s Medication Administration policy, last reviewed in November 2025, required that medications be administered at the time they are prepared. During a medication pass observation on March 4, 2026, at 8:47 a.m., a surveyor observed an RN retrieving medication cups with labels written in black marker from a medication cart on one nursing unit. In an interview at that time, the RN confirmed that she had pre-poured the medications into the medication cups, rather than preparing and administering them immediately as required by policy. This practice occurred in a medication cart on one of one nursing units and was cited under 28 Pa. Code 211.12(d)(1)(5) Nursing services. No additional information was provided in the report regarding specific residents, their medical histories, or their conditions at the time of the deficiency.
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