A facility failed to properly store and supervise medication administration for two residents. One resident had Artificial Tears at the bedside and self-administered them while an RN was present, but the RN left the room and the bottle was not kept in the med cart. For another resident, a nurse placed meds on the bedside table and left while the resident self-administered them, despite no physician order for self-administration; the RN and DON both confirmed the nurse should have stayed with the resident.
Expired meds were found in a medication cart and a med room, including Mirtazapine 15 mg for one resident and two OTC Bisacodyl 5 mg bottles. In addition, an RN left a med cart unlocked in a common area on a memory care unit while residents were present, and she confirmed the cart should have remained locked when unattended.
Surveyors found that the facility failed to remove expired medications from a medication storage room and a medication cart, including expired ibuprofen, cranberry pills, lorazepam, and liquid acetaminophen, despite a policy requiring expired drugs to be returned to the pharmacy or destroyed. They also observed multiple instances where an LPN left medication carts unlocked and unattended while entering resident rooms to administer medications, with residents present near the carts, contrary to the facility’s policy that medication carts not be left unattended if open or accessible.
Improper bedside storage of medications: Two residents had medicated products left on their bedside tables, including Biotene lozenges and a prescription topical ointment. One resident stated the lozenges were always kept at the bedside for self-administration, while the ADON confirmed these items should not be left at the bedside without an order for self-administration. Facility policy also prohibited bedside storage unless prescribed and deemed safe after a self-administration assessment.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
Surveyors found multiple instances where medication and treatment carts were left unlocked and unattended in resident-accessible corridors. On one unit, a medication cart and a treatment cart containing various medications, insulins, syringes, and prescription topical products were observed unlocked with a resident ambulating nearby, and the assigned RN confirmed they were not secured. On another occasion on the same unit, the medication cart was again found unlocked, which the RN Unit Manager acknowledged was contrary to expectations. On a different unit, a medication cart was observed unlocked and unattended with a resident sitting next to it, and the assigned LPN confirmed it should have been locked. The facility’s policy requires all medication compartments and carts to be locked when not in use and not left unattended if open.
Surveyors observed a medication cart in a hallway between resident rooms left unlocked and unattended while residents were self-propelling nearby. The cart contained OTC medications, syringes, topical agents, injectables, prescribed resident-specific medications, and narcotics in a separately locked compartment. An RN later returned to the cart and confirmed it had been left unlocked and acknowledged it should have been secured. The DON also confirmed that medication carts are required to be locked when not attended by the nurse on duty, demonstrating a failure to ensure all drugs and biologicals were stored in locked compartments for one of two medication carts.
Expired medications were found in the medication storage room, including Naproxen Sodium, Caltrate Bone Health Advance, Cranberry, Vitamin E, Vitamin D, CoQ10, Biotene Dry Mouth Rinse, Antidiarrheal, Acid Reducer, Bisacodyl, and stool softener. An LPN/Unit Manager confirmed the items were expired.
Expired COVID-19 vaccines were found in Unit B’s medication room freezer, and the RN Unit Manager confirmed they were ready for use and expired. The facility also left a medication treatment cart unlocked at the nursing station with medications inside while two residents were present nearby; an LPN later confirmed the cart should be locked and secured it.
Surveyors found expired and undated medications and medical supplies in all medication and treatment rooms inspected. Expired IV tubing kits, sterile water, injectable medications, auto injectors, blood collection sets, needleless connectors, foley care wipes, skin protectant ointments, and a catheter kit were confirmed by the Unit Manager, Nursing Manager, and an LPN. Items without expiration dates, such as glucose tablets and Vitamin B-Complex, were also present and acknowledged as needing removal.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.