F0761

D

Expired Medications and Unsecured Treatment Cart

Canonsburg, Pennsylvania Survey Completed on 04-10-2026

Penalty

No penalty information released

Summary

Surveyors found that the facility did not comply with its own medication storage policy and federal requirements for labeling and storage of drugs and biologicals. In the North Unit medication room, an observation revealed multiple expired items that had not been removed from inventory, including blood collection tubes with expiration dates ranging from the previous year to earlier in the current year, anaerobic and aerobic blood culture bottles past their expiration dates, glycerin swab sticks, hydrocortisone packets, hydrocolloid and foam dressings, Huber needle sets, and a silicone contact layer. The facility’s policy dated 1/5/26 required that outdated, contaminated, or deteriorated medications and those in compromised containers be immediately removed from inventory. An LPN confirmed during interview that the identified items were expired.

On a separate unit, surveyors observed a treatment cart that was unsecured inside a supply room with the door propped open. The cart contained two bottles of peroxide, one bottle of rubbing alcohol, multiple bottles of resident-specific ammonium lactate 12% lotion, several tubes of triamcinolone acetonide cream, and various bandages and gauze. The RN Assessment Coordinator confirmed that the treatment cart should be secured when unattended and that the supply room door should not be propped open. The Nursing Home Administrator later confirmed that the facility failed to ensure out-of-date medications were discarded in one medication room and failed to properly secure the treatment cart inside a propped-open supply room door.

Plan Of Correction

The DON/designee completed an OTC medication room audit on 3 units (North, South, West) for expired medications; all expired medications found were destroyed. The DON/designee will educate nursing staff on storing over-the-counter (OTC) medication according to manufactures guidelines for labeling and expiration dates, and ensure that treatment carts and the treatment room are locked.

This education will also be part of the Nursing New Hire process during orientation. Audits will be completed by the DON/designee on the storage of OTC medication according to manufacturer guidelines for labeling and expiration dates, and ensuring treatment carts and treatment rooms are locked.

These audits will be done four times weekly and three times monthly. The QAPI committee will review the results of these audits for further recommendations.