Surveyors found that the facility failed to remove expired medications from a medication storage room and a medication cart, including expired ibuprofen, cranberry pills, lorazepam, and liquid acetaminophen, despite a policy requiring expired drugs to be returned to the pharmacy or destroyed. They also observed multiple instances where an LPN left medication carts unlocked and unattended while entering resident rooms to administer medications, with residents present near the carts, contrary to the facility’s policy that medication carts not be left unattended if open or accessible.
Surveyors identified a repeat failure to properly store and dispose of expired medications across three units. Despite a policy requiring expiration dates to be checked before administration, multiple expired drugs were found in medication rooms and on a med/treatment cart, including numerous packs of nystatin oral suspension, Benzonatate 100 mg tablets, Aspirin 325 mg, and Ipratropium bromide/albuterol inhalation solution. Nursing staff confirmed that these medications were expired but remained in active storage areas.
Surveyors found multiple instances where medication and treatment carts were left unlocked and unattended in resident-accessible corridors. On one unit, a medication cart and a treatment cart containing various medications, insulins, syringes, and prescription topical products were observed unlocked with a resident ambulating nearby, and the assigned RN confirmed they were not secured. On another occasion on the same unit, the medication cart was again found unlocked, which the RN Unit Manager acknowledged was contrary to expectations. On a different unit, a medication cart was observed unlocked and unattended with a resident sitting next to it, and the assigned LPN confirmed it should have been locked. The facility’s policy requires all medication compartments and carts to be locked when not in use and not left unattended if open.
Surveyors observed a medication cart in a hallway between resident rooms left unlocked and unattended while residents were self-propelling nearby. The cart contained OTC medications, syringes, topical agents, injectables, prescribed resident-specific medications, and narcotics in a separately locked compartment. An RN later returned to the cart and confirmed it had been left unlocked and acknowledged it should have been secured. The DON also confirmed that medication carts are required to be locked when not attended by the nurse on duty, demonstrating a failure to ensure all drugs and biologicals were stored in locked compartments for one of two medication carts.
Surveyors found expired and undated medications and medical supplies in all medication and treatment rooms inspected. Expired IV tubing kits, sterile water, injectable medications, auto injectors, blood collection sets, needleless connectors, foley care wipes, skin protectant ointments, and a catheter kit were confirmed by the Unit Manager, Nursing Manager, and an LPN. Items without expiration dates, such as glucose tablets and Vitamin B-Complex, were also present and acknowledged as needing removal.
A medication treatment cart was found unlocked on a unit while a resident was present in the hallway. An LPN confirmed the cart should have been locked, as required by facility policy, which mandates all drugs and biologicals be stored in locked compartments.
An unopened Lidocaine 5% patch was left unsupervised on top of a medication cart by an LPN after a resident declined the medication. Multiple residents were present in the area at the time, and the medication was not secured or under direct observation as required by facility policy.
A pharmacy delivery was accepted by an LPN, who entered the medication room with the delivery person. The LPN then left the delivery person alone in the medication room for several minutes, which both the LPN and Administrator confirmed should not have occurred. This incident represents a repeat deficiency regarding unauthorized access to medication storage areas.
Surveyors found expired medications on two medication carts, including Isopto Atropine Solution 1% and Glutose 15. LPNs confirmed the presence of expired drugs and indicated that the night shift was responsible for checking for outdated medications.
A resident was found to have multiple topical medications unsecured in their shared room without a completed medication self-administration assessment. Staff confirmed that facility policy requires such an assessment and the use of a lock box for in-room medications, neither of which were in place.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
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.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account