Medication Storage and Administration Deficiencies
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with professional principles. During an observation of medication administration, a Licensed Practical Nurse (LPN) on the 2nd floor left a medication cart unlocked and unattended while using the telephone at the nursing station. The LPN acknowledged that the cart should have been locked when unattended, even though it was within sight. Additionally, a medical item was left on top of the cart, which should have been stored in the treatment cart. Another incident involved a Registered Nurse (RN) administering medication on the 2nd floor. The RN administered 15 ml of a solution as documented in the Electronic Medication Administration Record (EMAR), despite the bottle being labeled to administer 30 ml daily. This discrepancy between the labeled orders and the EMAR indicates a failure to follow proper medication administration protocols. The facility's policy on medication storage emphasizes that medications and biologicals should be stored safely and securely, accessible only to authorized personnel.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by the deficient practice. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken? All medication carts were audited for medications left unattended, and carts left opened at the time, no other deficiencies were found at the time. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur? All nurses will be educated on locking their medication carts, and ensuring no medications are left unattended. Random audits will be conducted weekly by the Pharmacy representative and/or designee. Any deficiency found will be addressed immediately. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? This corrective action plan will be monitored through a dedicated PIP and nursing home leadership will report findings to the monthly Quality and Risk Management committee. The committee will also evaluate the need for extended audits and further education, if necessary, after 90 days.
Penalty
Surveyors found multiple medicated ointments and topical solutions left at the bedside instead of in locked storage, including Diclofenac on a sink, a hydrophilic wound dressing in a basket on a nightstand for a severely cognitively impaired resident, and Ciclopirox solution on another nightstand. Facility policy requires all drugs and biologicals to be stored in locked compartments, and staff, including an LPN, the wound care nurse, and a CNA, stated that medications and ointments are to be kept on locked carts and not in resident rooms, yet these items remained accessible in resident rooms in violation of that policy.
A medication/treatment cart was found unlocked and unattended in a hallway. A nurse later admitted to leaving the cart unlocked by mistake while assisting a resident, and the DON confirmed that protocol requires carts to be locked when unattended. Facility policy also mandates that medications be stored in locked compartments accessible only to authorized personnel.
The facility failed to properly store medications, as expired Covid-19 test kits were found in a medication storage room, an unlocked medication cart was observed, and a nurse left a cup of crushed medication and a lancet unattended in a resident's room. The RN supervisor confirmed the expired kits, and the DON stated the tests could still be used due to an extended expiration date. The RN admitted to leaving the cart unlocked and the medication unattended due to being in a hurry and the presence of a surveyor.
The facility failed to properly store medications for several residents, with medications found at the bedside instead of in a locked medication room or cart. Observations included bottled pills, a bottle of medication, and a bingo card with discontinued medication improperly stored. Staff interviews revealed that rounds were conducted, but they were ineffective in identifying these storage issues.
The facility failed to properly store medications, as observed with loose pills in a medication cart and an unlocked lockbox in the medication storage room. The RN stated that carts are cleaned daily, and the ADON noted the lockbox issue was unreported.
Improper Bedside Storage of Topical Medications
Penalty
Summary
The deficiency involves failure to adhere to the facility’s own medication storage policy and state requirements for secure storage of drugs and biologicals. Surveyors observed medicated ointments and topical solutions stored at residents’ bedsides rather than in locked medication storage. On one observation, a container of Diclofenac ointment was found on top of the sink in the room of a resident admitted with heart failure and documented as having no cognitive impairment. In another observation on two separate days, a tube of hydrophilic wound dressing was seen in a basket on the nightstand of a resident admitted with a cerebral infarction due to embolism of the right middle cerebral artery, who was documented as severely cognitively impaired. A third observation found a container of Ciclopirox topical solution on the nightstand of a resident admitted with malignant neoplasm of overlapping sites of the bladder and no cognitive impairment. Record review of the facility’s “Storage of Medications” policy, revised January 2026, showed that all drugs and biologicals are to be stored in locked compartments under proper environmental controls. Staff interviews confirmed that the facility’s practice is that medications and ointments are to be kept on the locked cart and not allowed at the bedside, with staff stating that creams, ointments, and medicated nail polish are to be returned to the treatment cart after use, and that CNAs are to notify nurses if medications are seen in resident rooms. Despite these stated practices, surveyors found multiple medicated products left in resident rooms, demonstrating that medications were not consistently stored in locked or secure areas as required by policy and regulation.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. 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. MONITORINGNursing 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.
Unattended Unlocked Medication Cart
Penalty
Summary
A deficiency was identified when a medication/treatment cart was observed unlocked and unattended in the 300's hallway. The surveyor noted the unattended cart and confirmed with the nearest room that the assigned nurse was not present. Approximately ten minutes later, a wound care nurse returned to the cart and acknowledged that it should have been locked when unattended, explaining that the cart was left unlocked by mistake while assisting a resident. Further interviews with the Director of Nursing confirmed that facility protocol requires medication carts to be locked when not attended. Review of the facility's policy on Medication Labeling and Storage also states that all medications and biologicals must be stored in locked compartments accessible only to authorized personnel. At the time of the survey, there were 131 residents in the facility.
Plan Of Correction
Citation: F580 (D/N199-Class: Iif, Isolated) Corrective action(s) 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, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Identification of other residents having 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, to include 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, to include 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, to include 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. Following this, audits will 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. 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, to include 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: The findings of 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 action(s) 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 --- F761 (D/N95-Class: III, Isolated) On 06/17/2025, Staff A locked the medication/treatment cart after an interview with the surveyor. 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. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents who have the potential to be affected by this deficient 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. 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 action(s) 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
Medication Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications, as evidenced by several observations made by surveyors. In the West Wing medication storage room, a box containing multiple expired Covid-19 test kits was found. The Registered Nurse (RN) supervisor confirmed the expiration dates and removed the expired kits. The Director of Nursing (DON) later stated that the expired tests could still be used due to an extended expiration date listed on the FDA website, although the specific tests found expired were not covered by this extension. Additionally, an unlocked medication cart was observed on the West side nursing station. A Registered Nurse (RN) admitted to leaving the cart unlocked because they were in a hurry to assist residents. This action was contrary to the facility's policy, which requires medication carts to be locked when not in use to prevent unauthorized access. Furthermore, a surveyor observed a Registered Nurse (RN) leaving a resident's room with a cup of crushed medication and a lancet unattended. The RN left the room to retrieve an item needed for a procedure, leaving the medication and lancet accessible. The RN later stated that they left the items because the surveyor was present, although the proper protocol is to take medications and materials with them when leaving a room. The DON and Nursing Home Administrator were informed of this incident, and it was noted that the nurse was unaware that medications should not be left unattended.
Plan Of Correction
N095-FAC Drug Storage Identify patients that were at risk and what did: Once identified by surveyor the staff address of expired COVID Test, they were discarded. Central supply and Nursing managers educated immediately when identified by the surveyor and the Pharmacy consultant held a meeting with all nurses' about this topic on about expired medications and provided education. The nurse that left the medication cart unlocked was disciplined on Inservice with all nurses was done on to ensure compliance with Storage Biologicals Medications, Med Pass Administration and procedure by Pharmacist consultant. The DOH did a pharmacy audit on An. How will you identify other patents that are at risk: Medication Rooms and Medication Carts were checked for expired medications once identified by surveyor. DON and Nurse management checked med carts. The pharmacy was contacted to help with Med pass inservice and came to educate nurses on The Inservice included ensuring keeping carts locked when not in use and expired meds. Measures put in Place: The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with Medication Administration sample. The supervisor form will be handed to DON for compliance tracking. In-service completed by Pharmacy consultant on for all nurses on expired medications and provided education. Training was also done by the Consultant pharmacist on regarding any expired testing kits and or medications. The inservice also included ensuring keeping carts locked when not in use. The DON Created new audit tolls called on -Medication Cart Audit -Treatment Cart Audit -Med room Audit. Investigator from the Florida Department of Health Division of Medical Quality Assurance conducted an inspection No findings. How will you monitor: The Pharmacist will conduct a monthly audit of all medications and Carts. Nursing staff will conduct weekly audit of all medication and carts. The DON Managers and Consultant Pharmacist will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals for five residents, leading to a deficiency in compliance with the 59A-4.112(6), FAC Drug Storage regulation. Observations revealed that prescription and non-prescription medications were improperly stored at the bedside of several residents. For instance, a plastic bag of bottled pills was found on the nightstand of one resident, and a bottle of medication was observed on the side table of another resident. These medications were not secured in a locked refrigerator or medication room, as required by the regulation. Additionally, during a medication observation, two bottles labeled Acetic Irrigation Solution were found on the nightstand of a resident, which should have been stored in the medication cart. Another resident had a bingo card with discontinued medication in the medication cart, which should have been removed and either sent back to the pharmacy or destroyed. These findings indicate a lack of adherence to the facility's policy on medication storage, which mandates that all medications be stored according to the manufacturer's recommendations to ensure proper sanitation, temperature, light, moisture control, segregation, and security. Interviews with staff members, including LPNs and an RN, revealed that rounds were conducted to check the condition of residents and the environment for safety. However, the presence of medications at the bedside suggests that these rounds were not effective in identifying and addressing the improper storage of medications. The facility's failure to comply with the drug storage regulation was further confirmed by a review of the facility's policy and a statement from the Pharmacist Consultant, who emphasized the importance of removing discontinued medications from the cart.
Plan Of Correction
1. What corrective action will be accomplished? The bottled pills inside a plastic bag were removed from Resident #381's bedside and secured. The was removed from Resident #47's bedside and secured. The from Resident #12's bedside was removed and secured. The 2 bottles labeled Acetic Irrigation Solution were removed from Resident #47's bedside. The bingo card labeled tablet of discontinued medication for Resident #65 was returned to the pharmacy. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: The DON/Designee conducted an audit of occupied resident rooms and medication carts to ensure no medications or biologicals were at bedside and no discontinued medications were in the med carts. 3. Measures/systematic changes put into place: The DON/Designee re-educated the nursing staff on the facility policy for storage of medications and biologicals. Education for storage of biologicals was added to the new hire orientation and annual nursing education. The pharmacy nurse consultant will audit medication carts monthly to ensure no discontinued medications are stored in cart. 4. How corrective action will be monitored: The DON/Designee will conduct daily observation room rounds audit (times 5 weeks) to ensure no medications or biologicals are at bedside. Med cart audit for discontinued medications weekly (times 5 weeks). The results of these audits will be reviewed at the monthly QA meeting until compliance has been determined.
Medication Storage Deficiency
Penalty
Summary
The facility failed to provide appropriate storage of medications on one of the three medication carts observed. During an observation of medication Cart #3400 with a Registered Nurse (RN), three loose round white pills and several pieces of empty medication packaging were found in the second drawer of the medication cart. The RN revealed that the medication carts are cleaned daily on every shift, indicating a lapse in maintaining the medication cart in a secure and orderly manner. Additionally, during an observation of the medication storage room on the facility's second floor with the Assistant Director of Nursing (ADON), the lock box in the refrigerator was found unlocked. The lockbox contained an emergency kit with five vials of medication. The ADON attempted to secure the lock box with several keys but was unsuccessful, stating that the lock was warped and this issue had not been reported prior to the survey. The facility's policy requires that all drugs and biologicals be stored in a safe, secure, and orderly manner, which was not adhered to in this instance.
Plan Of Correction
DISCLAIMER STATEMENT: Preparation and/or execution of this plan of correction in general, or this corrective action in does not constitute an admission or agreement by this facility of the facts alleged or conclusions set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with state and federal laws. This plan of correction constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. 1. On , Staff C immediately discarded the 3 round white pills and empty medication packaging found in the second drawer of Medication Cart #3400. Staff C and ADON immediately deep clean Medication Cart #3400. On the lock box was repaired. On the lock box was replaced with a new lock box. 2. All residents have the potential to be affected by this deficient practice. Facility conducted an audit of all medication carts to ensure cleanliness of all medication carts. Facility conducted an audit of all lock boxes to ensure all lock boxes were working correctly and address, if needed. 3. The Director of Nursing, or designee(s) will educate all staff on Label, Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2), 59A-4.112(6), FAC Drug Storage and facility's Storage of Medications and Administering Medications policies and procedures. 4. The Nurses will conduct medication cart and lock box check daily. The Director of Nursing and/or designee will conduct a weekly medication cart and medication room quality review. The findings will be reported to the Quality Assurance Process Improvement (QAPI) committee monthly and then quarterly once substantial compliance has been achieved.
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