An unlocked treatment cart on Hall 400 was observed with insulin needles, lancets, breathing tx meds, ointments, lotions, and nutrition supplements inside. In addition, 4 of 4 med storage rooms observed on Halls 100, 200, 400, and 600 lacked proper temperature monitoring, with some rooms missing thermometers and one thermometer not working. Facility policy required med carts and supplies to be locked or attended and room-temp meds to be kept within the stated temperature range.
Unlocked Medication Cart Left Unattended: A CMA, while being trained by an LPN, left a medication cart unlocked while administering meds in a resident’s room about 55 feet away. The cart contained OTC items and resident meds, including Eliquis, metoprolol, methocarbamol, and furosemide. The CMA and LPN later acknowledged the cart had been unlocked, and the PC observed the storage issue.
Unsecured Medication Carts: A wound care cart and a nurse treatment cart were observed unlocked and unattended while containing medicated wound care cream, wound wash, and insulin. An LPN, the DON, and the administrator stated the carts should be locked when not in use, and an LPN said the treatment cart was left unlocked after answering the phone.
Expired and outdated medications were found on two medication carts during observation, including an expired vitamin, an expired vibegron bottle, an expired anti-diarrheal box, and opened latanoprost eye drops that had exceeded the stated use period. Staff, including medication aides, an LPN, the DON, the Administrator, and the Pharmacy Consultant, acknowledged that carts should be checked for expired medications, but the expired items remained on the carts.
Drugs and biologicals were not kept at proper temperatures in the medication refrigerator. Surveyors found only 2025 temperature logs, with no 2026 log present. An ADON stated they had never checked or completed the refrigerator temperature log and did not know who was responsible, and the DON stated the task was a nursing responsibility but was unsure when it stopped being done or why. The DON also stated there was no policy for refrigerated medications.
Medication Storage Not Secured: A clear plastic bag containing multiple medications waiting for destruction was observed sitting on the floor of the ADON's open office with no staff present. The facility policy required meds and biologicals to be securely maintained under lock and key, but the ADON stated she would lock them up later before destruction. The administrator said the ADON believed it was okay to leave them out because the surveyor was sharing the office.
Unsecured Medication Cart Left Unattended: A medication cart was observed unlocked and unattended on the south hall, with no staff in sight. The ADON walked to the cart and left without locking it, and a CMA later left the cart unlocked while helping another resident. Facility policy required medication carts to be securely locked when out of the nurse's view, and the ADON stated anyone could have taken the medications from the cart.
An LPN left medication carts unlocked and unattended during med pass, with the carts out of direct line of vision while the LPN walked down the hallway. The facility's policy required medication and treatment carts to remain locked when not under direct supervision and not be left unattended in hallways or resident rooms. The DON identified four medication carts, and two were observed unsecured.
Loose medications were found in the bottom of the North hall medication cart drawer during observation, including six tablets and one capsule. ACMA #1 stated loose pills were checked twice a week, but it had been a couple of days since the last check, and said any loose pills found during cart cleaning were to be reported to the charge nurse for destruction.
The facility failed to store refrigerated medications at the proper temperature and failed to secure controlled substances in locked storage. A medication room refrigerator contained tuberculin purified derivative at 50 degrees Fahrenheit with no temperature log documented, and an unlocked drawer in the DON’s office contained multiple controlled medications, including hydrocodone/acetaminophen, tramadol, Ativan, morphine, and ABH.
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