Surveyors found that insulin pens for two residents on a medication cart were not properly labeled, with one Lantus pen having an unreadable opened date and one Novolog pen lacking any opened or discard date, despite facility expectations that nurses label insulin with the date opened and expiration. In a medication room, a multidose vial of tuberculin solution was also found in use without an open date, even though staff acknowledged it should be dated and discarded within 30 days, contrary to the facility’s Storage of Medication policy requiring complete and accurate labeling of all drug containers.
Staff pre‑poured medications for 11 residents into medication cups that were stored in a medication cart drawer and labeled only with residents’ initials, without identifying the medications, doses, or administration instructions. A CMA acknowledged that facility policy required medications to be popped from bubble packs immediately before administration and not set up early, and an administrative nurse confirmed that medications were not to be prepared until a resident was ready to take them. This practice did not comply with the facility’s medication storage policy, which required proper labeling and storage of all medications and biologicals.
Surveyors found expired acetaminophen 650 mg suppository floor stock on the North Hall medication cart, despite facility policy requiring proper labeling, storage, and removal of expired drugs. A CMA and an administrative nurse each confirmed that medication aides or nurses were responsible for checking the cart and discarding expired medications, but the expired suppositories remained available on the cart.
Surveyors observed that a resident’s Novolog insulin pen on a medication cart was in use without an open or discard date, and a treatment cart contained four expired stock medications (aspirin, vitamin D, calcium with vitamin D, and zinc). A CMA verified the medications were expired, and an LN acknowledged that staff were required to date insulin pens when opened. These findings showed that staff did not consistently label insulin pens or remove expired stock medications as required by the facility’s medication storage policy.
Surveyors found multiple medication and treatment carts unlocked and unattended in hallways, despite containing enteral meds, PRN creams, insulin pens, scheduled meds, and OTC meds. On different units, carts were observed left without staff present while holding resident-specific and general treatment supplies. In interviews, an LN and an administrative nurse acknowledged that carts are required to be locked when out of view or not in use, and facility policy specified that medications must be stored in accordance with state and federal requirements.
Surveyors found that a medication cart on a resident hall was left unlocked with the keys in the lock and no staff present, despite facility policy that carts not be left unattended and unlocked. In the medication room, an opened vial of tuberculin lacked a date of opening and an expired bottle of latanoprost eye drops labeled for a resident remained in stock instead of being removed or returned to the pharmacy, contrary to the facility’s medication storage policy requiring locked storage and prompt disposal of outdated drugs.
Surveyors found that medication carts containing insulins and treatment supplies were left unlocked and unattended on two hallways, with carts observed open for several minutes while an LPN or a CMA was inside resident rooms or otherwise away from the carts. Staff acknowledged that carts are expected to be locked when not in use or out of direct eyesight, and facility policy requires carts to be kept in visible range or locked before entering a resident’s room.
Surveyors observed an RN using a hallway medication cart to prepare medications, then walking away into resident rooms while leaving the cart unlocked and unattended, with the lock not engaged and the cart out of staff visual range. The RN acknowledged that both the cart and computer monitor should be locked whenever unattended, and an administrative nurse confirmed this expectation. This practice did not comply with the facility’s Medication Labeling and Storage policy, which requires all medications to be stored in a secure, locked location accessible only to designated staff.
Unsecured controlled medications left in an unattended nurse’s station allowed two residents to access a red pharmacy bag containing alprazolam and lorazepam. One resident directed the other to take the bag, then brought it to his room and ingested multiple tablets, later presenting with lethargy, slurred speech, and repeated vomiting that led to hospital intubation and treatment for aspiration pneumonia. This resident had schizophrenia, severe depression, hallucinations, substance use issues, and intermittent passive suicidal ideation, with a care plan requiring ongoing assessment for suicidal thoughts. Conflicting staff statements showed that an LN signed for the delivery but did not secure the medications, and a CMA only put away non‑controlled medications. Missing narcotics for two other residents were later found hidden in a paper towel dispenser, and surveyor observation showed the nurse’s station could be easily entered while unattended, contrary to facility policies requiring secure medication storage and resident safety and supervision.
Surveyors found that insulin pens for a resident were not properly labeled when opened, in violation of professional standards and facility policy. On review of the med cart, one Lantus insulin pen lacked any opened or expiration date, and a second pen had an illegible, smeared date. Nursing staff, including an LPN and an administrative nurse, acknowledged that insulin pens are required to be labeled and dated when opened. The facility’s medication storage policy required medications to be labeled for individual residents and handled per manufacturer or supplier recommendations, and external guidance cited in the report specified that opened, unrefrigerated insulin pens are only usable for a limited number of days before they must be discarded.
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