Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
Medication Refrigerator Temperature Logs Not Consistently Maintained: The facility failed to consistently document refrigerator temperatures in 2 medication rooms where liquid meds and vaccines were stored. In one room, the thermometer read 28 degrees Fahrenheit, outside the required range, and review of the logs showed missing entries and inconsistent twice-daily monitoring. Staff acknowledged the documentation gaps and that the logs were not being maintained as required.
Surveyors identified that medications and biologicals were not properly managed in one South Unit medication room and on a medication cart. An LPN’s cart contained expired glucometer quality control solutions, though review of the log showed they had not been used for documented checks. In the South medication room, three bottles of Gericare Aspirin 325 mg were found past their manufacturer expiration dates, and the medication refrigerator was repeatedly below the required 36–46°F range while storing multiple insulin pens, Retacrit vials, Lorazepam vials, and Tubersol. Temperature logs documented several out-of-range readings with no recorded follow-up actions, and staff later acknowledged that expired aspirin had been missed during routine stock checks. The report states these failures placed residents at risk of receiving potentially compromised or expired medications.
Opened meds on two med carts were found undated, including eye drops and inhalers with specific discard times after opening. In addition, two cups of creams were repeatedly observed left at a resident’s bedside; the resident had moderate cognitive impairment and orders for Calmoseptine to the coccyx, and both an LPN and the DON stated the creams should not have been left in the room.
Improper medication storage, labeling, and temperature monitoring were observed in the facility. An LPN left a medication cart unlocked and unattended, open Glargine insulin pens in the cart lacked open or discard dates, a pill identified as Senna was found on the floor, and a cart laptop displayed a resident's PHI while the cart was unsecured. Vaccine refrigerator temperatures were documented only once daily despite CDC guidance for more frequent monitoring.
Surveyors found multiple medication rooms, medication carts, and a treatment cart unsecured or improperly labeled. An unlocked medication cart and treatment cart were left unattended with medications, syringes, creams, wound products, and other supplies accessible, and several opened medications in storage rooms lacked resident names or opening dates. Staff stated carts should be locked when unattended and medications should be labeled for resident safety.
Improper storage and altered manufacturer instructions for lorazepam. An unopened bottle of lorazepam oral concentrate for a resident was found stored at room temperature on the medication cart, despite the manufacturer’s directions for cold-temperature/refrigerated storage. The LPN and DON gave conflicting explanations about storage requirements, and the facility’s copy of the manufacturer instructions included an added discard statement that was not on the actual document.
Surveyors found that a treatment cart on one unit was left unlocked while an LPN was away at another medication cart, with open Derma Fungal cream, an odor eliminator, and other treatments easily accessible in its drawers despite facility policy requiring carts to remain locked. On another unit, an open tube of Refresh eye drops was left in a medication cup on top of a medication cart while an RN was several feet away at a different cart, after a resident had refused the drops. The Administrator and DON later acknowledged that carts should not be left unlocked and medications should not be left unattended on top of carts.
Expired meds were found on a medication cart and in a medication room, including an opened Haloperidol, Fiber Lax, and Povidone-Iodine swab sticks. An opened Lidocaine patch was also left on a resident’s dresser instead of being stored in the med cart, and staff confirmed it should not have been left there.
A registered nurse left medications unsecured on a medication cart during administration, and a supplement with an altered expiration date was found on a medication cart. Both the nurse and DON acknowledged that medications should be secured and properly labeled, and that expired medications should be discarded to ensure resident safety.
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