F761 · Drug labeling and storage

Based on medical record review, review of an emergency medical services (EMS) run report, review of hospital records, staff and family interviews, and facility policy review, the facility failed to ensure medications were appropriately secured and inaccessible to residents. This resulted in Immediate Jeopardy and serious life-threatening harm and negative health outcomes on 06/05/26 at approximately 9:00 A.M. when Resident #46 was observed to have multiple empty medication cards (packaged by pharmacy and provided specific labeling including the resident's name, medication name and dosage, and administration times) of Keppra (an anticonvulsant medication used to treat seizures) and Baclofen (a skeletal muscle relaxant and antispasmodic) each which had an original quantity of 30 and belonged… …

Orrville Pointe · Ohio

Based on interview, record review, and facility policy review, the facility failed to store all medications in a locked compartment and limit access only to authorized staff. Specifically, for 1 of 19 sampled residents, a resident was able to access the medication cart that was unlocked and unattended in a public hallway, allowing the resident to obtain multiple medications blister packs, and possibly ingest of unauthorized medication. This resulted in a finding of harm. Resident Identifier: 32.Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included human immunodeficiency virus, paranoid schizophrenia, and schizoaffective disorder.Review of resident 32's medical record was completed on 6/1/26 through 6/4/26.On 3/13/25 at 12:10 PM, an Event… …

Maple Ridge Rehabilitation and Nursing · Utah

Based on a review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to properly store resident medication on one of two nursing units (Main Unit).Findings include: The policy entitled Storage of Medications, last reviewed on March 31, 2026, with no changes, revealed compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Observation of the Main nursing unit on September 15, 2026, at 2:57 PM revealed an unattended and unlocked medication cart in front of the nursing station. The first drawer of the medication cart included resident specific medication. …

Rolling Hills Healthcare and Rehabilitation Center · Pennsylvania

Based on observation, interviews, facility documentation and facility policy for 1 of 2 medication storage rooms reviewed for medication storage, the facility failed to ensure the narcotic locked box containing 23 syringes of a compounded (custom made) medication gel of Ativan (schedule 4 controlled substance) 0.5 milligrams (mg), Benadryl 25mg, and Haldol 1mg (ABH gel) were secured in the medication refrigerator. The findings included: Observation on 7/9/26 at 8:00 AM of the medication refrigerator in the second-floor medication room identified the narcotic box was locked; however, the narcotic box was not secured to the inside of the medication refrigerator, and the medication refrigerator was not locked. …

Waterbury Center for Nursing & Rehabilitation LLC · Connecticut