Unlabeled Insulin Pens Found in Medication Cart
Summary
The deficiency involves the facility’s failure to ensure that medications were labeled and stored in accordance with professional standards and facility policy. A resident admitted with diagnoses including type 2 diabetes, vascular dementia, and congestive heart failure had physician orders for Humalog (therapeutic interchange for Novolog) insulin to be administered subcutaneously with meals per a specified sliding scale, and Lantus insulin to be administered daily at bedtime. The resident’s admission MDS showed impaired cognition with a BIMS score of 4/15 and a need for staff assistance with ADLs. During a medication pass observation, an LPN administered the resident’s morning medications and sliding scale insulin. In the top drawer of the medication cart, surveyors observed a Novolog insulin pen and a Lantus insulin pen with no labels indicating the resident’s name or insulin orders. In interview, the LPN confirmed that the insulin pens were not labeled with the resident’s name or orders and stated that the resident was the only person on the unit requiring insulin and that staff knew the pens belonged to that resident. Review of the facility’s Medication Storage policy indicated that medications are to be kept and stored in the packaging/containers dispensed by pharmacy that meet regulatory requirements, which was not followed in this instance.
Penalty
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A resident with mild cognitive impairment and multiple chronic conditions was found with a medication cup containing several pills and an inhaler left on the bedside table without a nurse present. A CNA confirmed the medications were unattended, and an LPN acknowledged she was responsible for them and that residents are supposed to be observed when taking medications. Facility policies required that medications be either under the direct observation of the person administering them or locked in a medication cart, and that staff observe residents consuming medications, but these requirements were not followed.
Surveyors found multiple instances where medications and biologicals were left unsecured and unsupervised in resident rooms, contrary to facility policy requiring safe, locked storage. One resident with significant neurologic and mobility impairments had diclofenac gel and an antiseptic solution left in the room, both labeled to contact poison control if ingested. Another resident with respiratory failure, a Foley catheter, and a G-tube had a prescription nystatin powder bottle sitting on the dresser, labeled for external use only and to contact poison control if ingested. A third resident with Parkinson’s disease and dementia had an Inbrija inhalation device left on the dresser without an order for bedside self-administration, which an LPN acknowledged should not have been in the room.
Surveyors found loose pills of various sizes and colors scattered in the top drawers of three medication carts beneath resident pill cards, indicating that medications were not properly stored. An LPN confirmed that pills found loose in the cart should have been discarded but were not, and the DON later acknowledged that while staff were expected to discard such pills, the facility’s medication storage and administration policies did not address procedures for handling loose medications in the carts.
A resident with multiple complex conditions, including ESRD, diabetes with neuropathy, post-stroke hemiplegia, vascular dementia, and cognitive communication deficit, had an order for Chlorhexidine 0.12% oral rinse to be given twice daily to swish and spit. Photos taken by the resident’s guardian showed a medicine cup with a capsule and a plastic cup containing yellow oral rinse left on the over-bed tray, indicating medications were left at the bedside. The guardian reported staff were supposed to stay until medications and the rinse were completed, and interviews with LPNs and a regional nurse confirmed that medications were not to be left at the bedside, in contrast to the facility’s medication administration policy.
Surveyors found that discontinued narcotic medications for multiple residents, including those who had died or been discharged, remained in locked medication carts instead of being removed and stored or destroyed per policy. Observations of several medication carts revealed leftover Tramadol, oxycodone-acetaminophen, lorazepam, morphine sulfate (including unopened bottles), and Percocet still assigned to residents no longer in the facility. LPNs confirmed the residents were discharged or deceased and that the narcotics had not been removed, and the Interim DON acknowledged awareness that expired narcotics remained in the carts despite a policy requiring discontinued controlled substances to be removed from patient care areas and secured until destruction.
The facility did not follow its policy requiring daily temperature checks of medication refrigerators, with multiple days lacking documented temperatures across several nursing stations and an entire month of logs missing. The Administrator confirmed the missing entries, and the DON reported that prior month temperature logs could not be located. This failure in monitoring and documentation affected the storage conditions of medications for all residents whose drugs were kept in these refrigerators.
Unsecured and Unsupervised Medications Left at Resident Bedside
Penalty
Summary
Surveyors identified a deficiency in medication administration and storage involving one resident. The resident had diagnoses including depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia, and COPD, and a recent MDS assessment documented mild cognitive impairment, no behaviors or refusals of care, use of a manual wheelchair, dependence for transfers, independent mobility, and a need for moderate assistance with activities of daily living. During observation of the resident’s room, surveyors found a medication cup on the bedside table containing one green oblong pill, one white oblong pill, and four white round pills, along with an inhaler next to the cup. At the time of this observation, no nurse was present in the room. A CNA confirmed the presence of the medications and inhaler on the bedside table, and an LPN later confirmed she was the nurse responsible for those medications. The LPN also confirmed that residents should be observed consuming their medications when they are administered. Review of the facility’s “Medication Administration” policy stated that nursing staff administering medications should observe the resident consuming their medications. Review of the facility’s “Medication Storage” policy stated that medications would be under the direct observation of the person administering medications or locked in a medication cart. The unattended medications at the bedside, not under direct observation or secured, were identified as an incidental finding during a complaint investigation.
Unsecured Medications and Biologicals Left in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were securely stored and not left unsecured in resident rooms. For one resident with cerebrovascular disease, right-sided hemiplegia, contractures, diabetes mellitus, decreased mobility, and a chronic skin condition, surveyors found two tubes of diclofenac sodium 1% gel and a bottle of Dyna-Hex 4 antiseptic solution left in the room, unsecured and unsupervised, despite orders for diclofenac gel to be applied topically for pain. Both products were labeled with instructions to contact poison control if ingested. The DON confirmed these items should not have been left in the room and should have been stored locked in the treatment cart. Another resident with acute on chronic respiratory failure with hypoxia, non-traumatic subarachnoid hemorrhage, hypothyroidism, decreased mobility, a Foley catheter, and a gastrostomy tube had a prescription bottle of nystatin powder 100,000 units/gram found sitting unsecured on the dresser, with a pharmacy label stating it was for external use only and to contact poison control if ingested; the resident’s physician orders were silent for any topical medications. A third resident with neurocognitive disorder with Lewy bodies, dementia with psychotic disturbances, delusions, and Parkinson’s disease had an Inbrija (Parkinson treatment) inhalation device found on the dresser, unsecured and unsupervised, despite an order for PRN inhalation and no order for bedside self-administration. An LPN confirmed the inhaler should not have been left in the room, and the facility’s “Storage of Medication” policy required all drugs and biologicals to be stored in a safe, secure, and orderly manner.
Improper Storage and Handling of Loose Medications in Multiple Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and handled in medication carts, as required for drugs and biologicals. During an observation of the Central One medication cart with an LPN on 04/07/26 at 9:23 A.M., surveyors found 20 loose pills of various sizes and colors scattered on the bottom of the top drawer under resident pill cards. A subsequent observation of the Central Two medication cart with the same LPN revealed eight loose pills, also of different sizes and colors, scattered on the bottom of the top drawer under pill cards. The LPN confirmed that both carts contained scattered pills and acknowledged that the medications were not properly stored, stating that the expectation was for staff to discard any medications that fell from pill cards into the drawer. Later that day at 12:00 P.M., an observation of another medication cart ([NAME] Two) with a different LPN revealed ten loose pills of varying sizes and colors scattered on the bottom of the top drawer under pill cards. This LPN also confirmed that the pills were not stored properly and should have been discarded. In an interview on 04/08/26 at 8:46 A.M., the DON stated the facility had a total of six medication carts and confirmed that staff were expected to discard any pills found on the bottom of the medication cart drawers. The DON further confirmed that the facility’s medication storage and medication administration policies did not address staff procedures for handling loose pills found in the medication carts. This non-compliance was investigated under Complaint Number 2806644.
Medications Left Unattended at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were not left at a resident’s bedside, contrary to facility policy and accepted standards for medication security. Resident #7, admitted on 11/28/25, had diagnoses including end stage renal disease, dependency on dialysis, type II diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, vascular dementia, and cognitive communication deficit. Physician orders for December 2025 included Chlorhexidine Gluconate 0.12% mouth/throat solution, 15 ml PO every morning and at bedtime, to swish and spit following teeth extractions. Photos provided by the resident’s guardian, dated 12/20/25 at 7:32 A.M., showed a medicine cup on the resident’s over-bed tray with one capsule in it and a plastic drinking cup containing a yellow/pale fluid. In a telephone interview, the guardian identified the yellow/pale fluid in the plastic cup as the resident’s oral rinse and stated that staff were supposed to remain with the resident until medications were taken and the rinse was completed as ordered. Interviews with two LPNs on 03/30/36 and with a Regional Nurse on 04/02/26 confirmed that medications were not to be left at the bedside and that the photo depicted a medicine cup with one capsule and a plastic cup with yellow/pale fluid. Review of the facility’s “Administering Medications” policy, revised December 2012, indicated that medications were to be administered in a safe and timely manner and as prescribed. The surveyors concluded that the facility failed to ensure medications were not left at the bedside for this resident, resulting in noncompliance under Complaint Number 2721789.
Failure to Timely Remove and Dispose of Discontinued Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to timely remove and properly dispose of discontinued narcotic medications, including those for residents who had died or been discharged. Surveyors reviewed records and medication carts and found multiple instances where controlled substances remained in the narcotic drawers after the medications had been discontinued or the residents were no longer in the facility. For one resident who had expired, 15 tablets of Tramadol 50 mg remained in the 100-hall medication cart. Another resident with end stage renal disease, congestive heart failure, and multiple malignancies had 22 tablets of discontinued Tramadol HCL 50 mg still stored in the 300-hall medication cart after discharge. Additional observations showed that a resident with anxiety, hemiplegia, hemiparesis, and adjustment disorder had 22 tablets of discontinued oxycodone-acetaminophen 10-325 mg remaining in the narcotic drawer. A resident with dementia, schizophrenia, atrial fibrillation, and congestive heart failure who had been transferred out still had 23 tablets of discontinued Tramadol 50 mg in the cart. Another resident with hip fracture, dementia, anxiety, bipolar disorder, and diabetes mellitus who had expired had 29 tablets of Tramadol 50 mg, 31 tablets of lorazepam 0.5 mg, and a full unopened bottle of liquid morphine sulfate remaining in the locked narcotic drawer. Surveyors also identified that a resident with thoracic vertebra fracture, quadriplegia, contracture, and left shoulder stiffness who had been discharged still had 20 oxycodone-acetaminophen 5-325 mg tablets in the narcotic drawer, and a resident with Alzheimer’s disease, dementia, chronic kidney disease, and peripheral vascular disease who had expired under hospice care had 28 lorazepam 0.5 mg tablets and an unopened bottle of morphine sulfate concentrate remaining in the cart. A resident with migraine, osteoarthritis, heart disease, and Parkinsonism who had discharged to another LTC facility still had 22 Percocet 10-325 mg tablets in the narcotic drawer, despite active orders having been discontinued or the resident no longer being present. LPNs confirmed that these residents were no longer in the facility and that their narcotics remained in the medication carts, and the Interim DON acknowledged awareness that expired narcotics remained in the carts. Facility policy stated that discontinued controlled substances were to be removed from patient care areas and temporarily stored in a securely locked area until destruction, which was not followed in these cases.
Failure to Perform and Document Daily Medication Refrigerator Temperature Checks
Penalty
Summary
The facility failed to ensure medication refrigerators were monitored and maintained according to its policy requiring daily temperature checks for all medication storage refrigerators. Review of the Station #1 Unit Temp Log Check form for 03/01/26 to 03/20/26 showed no documented refrigerator temperatures on 03/05/26, 03/13/26, and 03/19/26. Review of the Station #2 Unit Temp Log Check form for the same period showed no documented refrigerator temperatures on 03/02/26, 03/03/26, 03/04/26, 03/05/26, 03/07/26, 03/08/26, 03/09/26, 03/10/26, 03/12/26, and 03/13/26. Review of the Station #4 Unit Temp Log Check form for 03/01/26 to 03/20/26 showed no documented refrigerator temperature on 03/17/26. The Administrator confirmed these missing temperature checks during an interview, and the DON confirmed that the refrigerator temperature logs for 02/01/26 to 02/28/26 were missing and could not be located. The undated Medication Refrigerator Temperature Check Policy stated that all medication refrigerators were to be checked daily to ensure they remained within the proper temperature range. This deficiency had the potential to affect all 78 residents in the facility and was investigated under Complaint Number 2786595. No specific residents, medical histories, or clinical conditions were identified in the report; the deficiency related broadly to the management and monitoring of medication refrigerator temperatures for all residents whose medications were stored in these units.
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