Medication Labeling Deficiency
Summary
The facility failed to ensure that all drugs used were labeled in accordance with clinical professional standards. During an inspection of a medication cart on two floors, it was observed that two translucent brown medication bottles had labels with spaces to write the medication expiration date and the date the medication was first used, but no information was written on them. Additionally, an injector pen was found with a label to document the 'date opened' and instructions to discard after 28 days, but the necessary dates were not documented. Staff A, a Registered Nurse, admitted to not knowing the expiration dates and acknowledged that the labels should have been dated. Further observations on a second-floor medication storage cart revealed another injector pen without the open date and discard date listed. Staff B, an LPN, confirmed that the pen should be discarded 28 days after first use and immediately removed it from the cart. The Director of Nursing stated that the facility expects staff to write the medication expiration dates on the labels when medications are first used. The facility's policy on Medication Administration requires medications to be administered by licensed nurses in accordance with professional standards to prevent contamination, but this was not adhered to in these instances.
Plan Of Correction
Identified and injector pens were discarded on. New medications were provided by the pharmacy and dated appropriately. Quality review was conducted on, by Director of Nursing/designee, of current medication carts to ensure proper labeling/storage of drugs and biologicals with emphasis on medications being dated at time of opening and discarding medication when expired. Any concerns noted were addressed as identified. Current Licensed Nurses were re-educated by Director of Nursing/designee on the components of this regulation with emphasis on ensuring proper labeling/storage of drugs and biologicals with emphasis on medications being dated at time of opening and discarded at time of expiration. The Director of Nursing/designee to conduct quality monitoring of medication carts to ensure proper labeling/storage of drugs and biologicals with emphasis on medications not being dated when opened and expired drugs twice weekly x 4 weeks, weekly x 2 weeks; then weekly and PRN as indicated. The findings of these quality monitorings to be reported to the Quality Assurance/Performance improvement Committee monthly. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/designee.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
