Unsecured Medicated Ointments and Solutions Left in Resident Rooms
Summary
Surveyors identified a deficiency in the facility’s labeling and storage of drugs and biologicals when medicated ointments and solutions were found unsecured in multiple resident rooms on the second floor. During observation, a container of Diclofenac ointment was seen on top of the sink in one resident’s room, and a container of Ciclopirox topical solution was observed on another resident’s nightstand. Both of these residents’ clinical records showed they had no cognitive impairment, with diagnoses including heart failure for one resident and malignant neoplasm of overlapping sites of the bladder for the other. Additional observations showed a tube of hydrophilic wound dressing stored in a basket on a different resident’s nightstand on two separate occasions. Clinical records for this resident indicated admission with a diagnosis of cerebral infarction due to embolism of the right middle cerebral artery and severe cognitive impairment. These findings conflicted with the facility’s written “Storage of Medications” policy, revised January 2026, which states that all drugs and biologicals are to be stored in locked compartments under proper environmental controls. Staff interviews confirmed that medications and ointments were expected to be kept on locked carts and not at the bedside, and that residents were not allowed to keep medications in their rooms, indicating that the observed bedside storage of medicated products did not comply with facility policy and regulatory requirements.
Plan Of Correction
The facility continues to ensure that all drugs and biologicals are stored appropriately. IMMEDIATE CORRECTIVE ACTION Medications were immediately removed from room for residents #58, #20, and #29 on 5/11/26. Residents #58, #20, and #29 were not adversely affected by alleged deficient practice. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. No residents were adversely affected by the alleged deficient practice. Director of Nursing and/or designee conducted a facility-wide observation audit to ensure that drugs and biologicals are stored appropriately on 05/12/2026. SYSTEMATIC CHANGES The Director of Nursing and/or designee initiated ongoing in-service education with staff on standards. of drug and biological storage on 05/20/2026. MONITORING Nursing Supervisor and/or designee will conduct random observation audits to ensure drugs and biologicals are stored appropriately, 5 days a week for 1 month, then weekly for 3 months. The Director of Nursing and/or designee will report findings of observation/audits to the quality assurance committee monthly for 4 months to ensure continued substantial compliance.
Penalty
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Surveyors found that a medication room refrigerator on one unit contained five bottles of liquid Ativan, a controlled medication used to treat anxiety, stored together with non-narcotic medications without a separately locked, permanently affixed compartment. An LPN and the Nursing Home Administrator both confirmed that the Ativan was not secured in a distinct locked area as required for controlled substances.
Surveyors found multiple instances where medications and biologicals were left unsecured at bedside, contrary to facility policy and staff expectations. A resident with type 2 DM and hyperglycemia had a metformin tablet left in a cup on the bedside table, while another resident’s zinc oxide ointment was left on the bedside table when the resident was not present. In a third case, three ampules of ipratropium-albuterol were left at bedside next to a nebulizer for a resident with a PRN order for SOB/wheezing, also while the resident was absent. Staff, including an LPN and the DON, acknowledged that medications and treatments should not be left unattended and that medications are to be stored in locked compartments with access limited to authorized personnel.
Surveyors identified multiple failures in medication labeling, dating, and storage, including an illegible lorazepam label in the refrigerator, an opened tuberculin vial and a Hepatitis B vaccine syringe improperly stored, and a non–permanently affixed locked box containing insulin and narcotics in the medication refrigerator. In a medication cart, loose unlabeled pills and various identified tablets were found in drawers, and a bottle of glucose test strips in use lacked an open date despite manufacturer instructions. An unattended medication cart was also observed with a pill on the floor nearby, which an LPN later admitted she had dropped and not properly located and destroyed.
Surveyors found expired acetaminophen 650 mg suppository floor stock on the North Hall medication cart, despite facility policy requiring proper labeling, storage, and removal of expired drugs. A CMA and an administrative nurse each confirmed that medication aides or nurses were responsible for checking the cart and discarding expired medications, but the expired suppositories remained available on the cart.
Surveyors identified that the facility failed to remove multiple expired medications and medical supplies from a medication room, including blood collection tubes, culture bottles, topical agents, dressings, and needle sets, despite a policy requiring immediate removal of outdated items. On another unit, a treatment cart containing peroxide, rubbing alcohol, resident-specific ammonium lactate 12% lotion, triamcinolone acetonide cream, and various dressings was left unsecured in a supply room with the door propped open. An LPN and an RNAC confirmed the expired items and the expectation that the cart and room should be secured, and the NHA acknowledged these failures.
Surveyors observed that a resident’s Novolog insulin pen on a medication cart was in use without an open or discard date, and a treatment cart contained four expired stock medications (aspirin, vitamin D, calcium with vitamin D, and zinc). A CMA verified the medications were expired, and an LN acknowledged that staff were required to date insulin pens when opened. These findings showed that staff did not consistently label insulin pens or remove expired stock medications as required by the facility’s medication storage policy.
Improper Refrigerator Storage of Controlled Liquid Ativan
Penalty
Summary
Surveyors identified a deficiency related to the labeling and storage of drugs and biologicals, specifically the failure to provide a separately locked, permanently affixed compartment in a medication room refrigerator for controlled drugs. During an observation of the Landings unit medication room, surveyors noted that a small locked refrigerator contained five bottles of liquid Ativan, a controlled medication used to treat anxiety. These bottles were stored together with non-narcotic medications and were not placed in a distinct, separately locked compartment as required for controlled substances. At the time of the observation, an LPN confirmed that the five bottles of liquid Ativan were not secured in a separate locked compartment from other non-narcotic medications. Later, the Nursing Home Administrator also confirmed that the liquid Ativan was not stored in a separately locked, permanently affixed compartment within the refrigerator. The deficiency was cited under federal requirements for storage of controlled drugs and the related state pharmacy services regulation.
Plan Of Correction
Upon identification, the controlled drugs were relocated to another nursing unit secured medication refrigerator and housed in a separately locked, permanently affixed compartment in the refrigerator. Medication room refrigerator controlled drug box was secured and medications returned to the refrigerator on the assigned unit. The Director of Nursing and/or designee will re-educate current in-house and agency Nursing Staff on the requirement for storage of controlled drugs in a separately locked, permanently affixed compartment in the refrigerator separate from other non-narcotic medications. Newly hired and agency Nursing staff will be educated on the storage of controlled drugs in a separately locked, permanently affixed compartment in the refrigerator separate from other no- narcotic medications. Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that controlled drugs are stored in a separately locked, permanently affixed compartment in the refrigerator separate from other non-narcotic medications. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Unsecured Medications and Biologicals Left at Bedside
Penalty
Summary
Surveyors identified a failure to ensure drugs and biologicals were stored and labeled in accordance with accepted professional principles on two of three units. In one room, a white oval tablet was observed in a medication cup on a bedside table; the resident stated it was metformin, and the physician’s order documented metformin 1000 mg by mouth twice daily for type 2 diabetes mellitus with hyperglycemia. Nursing staff and the DON both stated that medications should not be left at a resident’s bedside and that staff are expected to remain with residents until medications are taken, indicating that the presence of the metformin tablet at bedside was inconsistent with facility expectations and that this resident would not be allowed to self-administer this medication. In another room, zinc oxide ointment was observed on top of a bedside table while the resident was not present, and an LPN acknowledged that the ointment should not have been there. In a third room, three ampules of ipratropium-albuterol were found at the bedside next to a nebulizer machine while the resident was not in the room; the resident had a physician’s order for ipratropium-albuterol inhalation every six hours as needed for shortness of breath or wheeze. The LPN stated that the ipratropium-albuterol should not have been in the room. The facility’s written policy on “Medication Labeling and Storage” stated that all medications and biologicals are to be stored according to manufacturer recommendations in locked compartments under proper environmental controls, with access limited to authorized nursing and pharmacy personnel, which was not followed in these instances.
Improper Medication Labeling, Dating, and Storage in Medication Room and Cart
Penalty
Summary
The deficiency involves failure to ensure medications and biologicals were properly labeled, dated, and stored in accordance with facility policy and professional standards in both the medication room and a medication cart. In the medication room, surveyors observed a bottle of liquid lorazepam in the refrigerator with an illegible label on both the bottle and box, and the LPN present was unsure whether it should be refrigerated. A vial of tuberculin purified protein derivative was found with an open date of 11/24/25, and the LPN did not know how long it remained usable after opening. A Hepatitis B vaccine syringe with an expiration date of 7/7/25 was also stored in the refrigerator, and the LPN acknowledged it should not have been there. A metal box containing insulin and narcotics from the pharmacy was found in the refrigerator; it was locked but not permanently affixed, and staff stated the narcotics could not be moved to the refrigerator’s lock box due to pharmacy key and assignment issues. The DON later confirmed the narcotics box should have been permanently attached to the refrigerator. In the west hall medication cart, surveyors found multiple loose, unlabeled pills in drawers, including three small round white pills and several identified tablets (duloxetine, Lasix, atorvastatin in multiple strengths, divalproex, pantoprazole, and quetiapine), and the LPN acknowledged these loose pills should not have been in the cart. A bottle of Evencare ProView glucose test strips in use for a resident’s blood sugar check lacked an open date, and the RN using them stated the bottle should have had an open date but was unsure how long the strips were good after opening, despite the operator’s manual specifying dating and discard timeframes. Additionally, an unattended medication cart was observed near the nurses’ station with a round white pill on the floor nearby; the LPN later stated she had dropped the medication earlier, could not find it, and admitted she should have moved the cart to locate and destroy the medication but had not done so.
Expired Floor Stock Medication Found on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of medication storage when, during observation of the North Hall medication cart on 04/13/2026 at 08:10 AM, they found four acetaminophen 650 mg suppositories with an expiration date of 3/2026 still present as floor stock. Certified Medication Aide R confirmed at 08:15 AM that medication aides or nurses were responsible for discarding expired medications. On 04/15/2026 at 02:30 PM, Administrative Nurse E also verified that medication aides or nurses were expected to check the medication cart and discard expired medications. The facility’s Medication Labeling and Storage policy, dated 01/22/2026, required that medications be labeled and stored in accordance with facility requirements and State and Federal laws, and that floor stock medications be kept in the original manufacturer’s container with the expiration date and lot number clearly evident, yet the expired acetaminophen suppositories remained on the cart. No specific residents or their medical histories were mentioned in relation to this deficiency, and the findings were limited to the presence of expired stock medication on the North Hall medication cart and staff acknowledgments of their responsibility to remove such medications.
Expired Medications and Unsecured Treatment Cart
Penalty
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.
Failure to Label Insulin Pen and Remove Expired Stock Medications
Penalty
Summary
Surveyors found that the facility failed to properly label and store medications and biologicals as required by facility policy and professional standards. During observation of the 100–200 hall medication cart at 8:05 AM, an insulin pen (Novolog) for Resident 41 was found without an open date or discard date. In a separate observation of the treatment cart at 8:15 AM, four bottles of stock medications were found to be expired: aspirin 325 mg (expired 01/26), vitamin D tablets (expired 03/26), calcium 600 mg with vitamin D 5 mcg (expired 07/25), and zinc 50 mg tablets (expired 01/26). A certified medication aide confirmed that the stock medications were expired, and a licensed nurse confirmed the insulin pen was undated and stated that staff were supposed to date insulin pens when opened. The facility’s Medication Storage policy, dated 03/2026, stated that all drugs and biologicals would be stored in a safe, secure, and orderly manner and that discontinued, outdated, or deteriorated drugs or biologicals would not be used and would be returned to the pharmacy or destroyed per state regulations. These observations and staff confirmations demonstrated that the facility did not ensure insulin pens were dated when opened and did not remove expired stock medications from use, contrary to its own policy and accepted standards for medication storage and labeling.
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