Unattended Unlocked Medication Cart Observed
Summary
A deficiency occurred when a medication/treatment cart was observed unlocked and unattended in the 300's hallway. The surveyor noted the unattended cart and, upon inquiry, found that the assigned nurse was inside a resident's room. The nurse, identified as a wound care nurse, acknowledged that the cart should always be locked when unattended and admitted to leaving it unlocked by mistake while assisting a resident. The facility's policy requires all medications and biologicals to be stored in locked compartments with access limited to authorized personnel. The observation and subsequent interviews confirmed that the cart was not secured as required, resulting in a failure to properly store medications in accordance with federal regulations. There were 131 residents in the facility at the time of the survey.
Plan Of Correction
Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. On 06/18/2025, Assistant Director of Nursing provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. The Assistant Director of Nursing, or designee, will conduct random audits of medication/treatment carts. Audits will be no less than 5 audits weekly across all shifts for 3 weeks. Any deficiencies observed will be corrected immediately. No less than 5 audits will be completed monthly thereafter. The frequency of audits will be determined by the QAPI and QAA Committees. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Citation: F580 (D/ N199-Class: III, Isolated). Corrective actions will be accomplished for those residents found to have been affected by the deficient practice. Due to the date of the incident involving Resident #1 (01/23/2023), corrective action for notification could not be accomplished. On 1/24/2023, the Admissions Coordinator updated the demographic sheet to reflect Resident #1's Responsible Party/Emergency Contact. On 6/20/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Identification of other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly, to ensure that the resident's responsible party/emergency contact, if any, was notified of the treatment change. Identification of other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, including but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly, to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition for all incidents weekly for 2 weeks. Any problems with notification will be promptly resolved. Audits will then be conducted at random for 2 additional weeks of at least 20% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period. Any problems with notification will be promptly resolved. Monthly audits of at least 25% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period will be conducted to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Frequency of audits will be determined by the QAPI and QAA Committees. On 6/23/2025, the Admissions Coordinator notified the MDS Coordinator of the need to review the resident's demographics sheet to ensure that the resident's responsible party/emergency contact information, if any, is listed and is accurate during care plan meetings. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025. F0761 practice. On 6/22/2025, the Director of Nursing, or designee, observed all medication/treatment carts were locked as appropriate. No other carts were identified to be out of compliance at that time. On 06/18/2025, Assistant Director of Nursing provided education to Staff A on the need to ensure medication/treatment carts are locked when unattended. On 06/18/2025, Assistant Director of Nursing provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. On 06/18/2025, Assistant Director of Nursing, provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. The Assistant Director of Nursing, or designee, will conduct random audits of medication/treatment carts. Audits will be no less than 5 audits weekly across all shifts for 3 weeks. Any deficiencies observed will be corrected immediately. No less than 5 audits will be completed monthly thereafter. The frequency of audits will be determined by the QAPI and QAA Committees. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025.
Penalty
Resources
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Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
Surveyors found that the facility failed to follow its own medication storage policy when medicated ointments and solutions were left unsecured in several resident rooms. A resident with heart failure had Diclofenac ointment on the sink, another resident with bladder cancer had Ciclopirox topical solution on the nightstand, and a severely cognitively impaired resident with a history of cerebral infarction had hydrophilic wound dressing stored in a bedside basket on multiple observations. Staff, including an LPN, a wound care nurse, and the ADON, stated that medications and ointments were supposed to be kept on locked carts and not at the bedside, and that residents were not permitted to keep medications in their rooms, demonstrating noncompliance with the facility’s written storage policy and federal requirements.
Medication cart security was not maintained for Cart 700. Facility policy required the cart to be locked when out of the medication nurse’s sight, but an RN walked away from the cart and later entered a resident room while leaving it unlocked and unattended. The RN confirmed the cart should have been locked, and the President of Clinical Operations confirmed carts should be locked when unattended.
Insulin Storage and Labeling Deficiency: The short hall med cart contained multiple insulin items that were not properly dated, including an open Lantus vial, an unopened Novolin vial, a Lantus pen, and a Novolog pen. The ADON said insulin containers should be dated for 28 days when removed from refrigeration and opened, but she was unsure when the items were taken out. The DON also confirmed insulin should be labeled with the expiration date when removed from the refrigerator, and the facility policy required pens to be dated when placed into use.
Loose medications were found in 2 of 8 observed med carts, including five loose pills in one cart, one loose pill in another, and one loose blue pill in a third cart. A bottle of Active Liquid Protein also lacked an open date. Staff interviews confirmed that carts are checked by nurses, unit managers, DON, and pharmacy, and the facility policy requires the date opened to be recorded on multi-dose containers.
Surveyors found multiple expired medications, including various insulin products, Trulicity injection pens, and a large bottle of Gabapentin solution, stored in a medication room refrigerator and still available for use. The MDS coordinator confirmed the drugs were expired. The DON reported that no one had been specifically assigned to check the refrigerator for expired medications, while an LPN stated she only reviewed medication carts and did not check refrigerated stock. Facility policies required checking expiration/beyond-use dates before administration, dating multi-dose containers when opened, discarding them within specified time frames, and returning or destroying outdated medications, but these procedures were not followed for the medications in the refrigerator.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsecured Medicated Ointments and Solutions Left in Resident Rooms
Penalty
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.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure medications were securely stored in 1 medication cart, Cart 700, out of 3 medication carts reviewed. The facility policy titled, Medication Administration General Guidelines, dated 9/18, stated that during medication administration, the medication cart is to be kept closed and locked when out of sight of the medication nurse. During observation on 5/12/2026 at 7:40 AM, RN A walked away from Cart 700, leaving the cart unlocked and unattended. During another observation on 5/12/2026 at 8:01 AM, RN A entered room [ROOM NUMBER] and again left the medication cart unlocked and unattended. RN A later confirmed she should have locked the medication cart when it was left unattended, and the [NAME] President of Clinical Operations confirmed the medication carts should be locked when left unattended.
Insulin Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, including the expiration date for 1 of 2 medication carts reviewed for medication storage. During an observation and interview with the ADON, the short hall medication cart was found to contain a Novolog insulin pen dated [DATE], an open Lantus insulin vial that was undated, an unopened Novolin insulin vial in the manufacturer’s box that was undated, a Lantus insulin pen that was undated, and a Novolog insulin pen that was undated. The ADON stated that all insulin containers should be dated for 28 days when removed from the refrigerator and opened, and she was unsure when the five insulin containers had been removed from the refrigerator. The ADON said it was the nurse’s responsibility to maintain the contents of the carts and that the nurse responsible for the cart had left work early. She was unsure whether the date on the Novolog pen was the expiration date or the date the pen was opened. In an interview with the DON, she stated that all insulin containers should be labeled with the expiration date by the nurse as soon as they are removed from the refrigerator, and she was unsure why the cart contained inaccurately labeled insulin pens and vials. The facility policy titled Insulin Pen Use stated that once an insulin pen is taken out of cool storage, it can be used for up to 28 days and must be dated when placed into use.
Loose medications and missing open date in medication carts
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with accepted professional principles for 2 of 8 medication carts observed. During observation on 05/07/2026, RN B’s medication cart contained five loose pills, and RN A’s medication cart contained one loose pill. LVN D’s medication cart also contained one loose, small round blue pill, and a bottle of Active Liquid Protein did not have an open date written on it. Staff interviews confirmed that loose medications were found in the carts and that the open date was not documented on the liquid protein container. During interviews, RN B stated nurses, unit managers, the DON, and pharmacy check medication carts, and that pharmacy checks them monthly. RN A stated loose pills in the medication cart could cause confusion. LVN D stated staff would not be able to identify a medication if it was loose in the cart and reported loose pills were disposed of in the pill incinerator. The DON stated nurses should clean their medication carts after each shift and that staff are expected to write the open date on medications, while the ADM stated staff should check their medication carts to ensure there are no loose pills. The facility policy stated the expiration or beyond-use date is checked before administering medications and that when opening a multi-dose container, the date opened is recorded on the container.
Expired Medications Not Removed From Medication Room Refrigerator
Penalty
Summary
Surveyors identified a failure to properly manage and discard expired medications stored in a medication room refrigerator. During an observation of the medication storage room refrigerator with the Minimum Data Set Coordinator, multiple expired medications were found, including one Lispro insulin vial and one Lantus insulin vial, both with expiration dates of 01/23/26 and no open dates on the vials. An Apidra Solostar insulin pen with an expiration date of 02/04/26, a Trulicity 3 mg/0.5 ml injection pen carton with two pens remaining and an expiration date of 01/16/26 with no open date on the carton, and a 500 ml bottle of Gabapentin solution with 450 ml remaining and an expiration date of 10/02/23 with no open date on the bottle were also present. These medications remained stored in the refrigerator and available for use despite being outdated. During interviews, the MDS Coordinator confirmed that the medications in the storage refrigerator were expired and stated that an LPN was responsible for monitoring medication expiration dates for medications stored there. The DON reported that she did not think anyone had been assigned to check the medication storage refrigerator for expired medications and acknowledged that expired medications should have been destroyed by staff or returned to the pharmacy. The LPN later stated that she reviewed all medication carts for expired medications but did not check the medications stored in the refrigerator. Review of facility policies showed requirements that expiration or beyond-use dates be checked prior to administration, that multi-dose containers be dated when opened and discarded within 28 days unless otherwise specified, and that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, which were not followed in this instance.
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