Drug labeling and storage · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Based on record reviews, staff interviews, and review of other pertinent information, it was determined that the facility failed to keep and maintain a safe and effective system for securing and counting narcotic medications. This was evident for 2 out of 7 medication carts reviewed for medication storage.
These actions resulted in the finding of an Immediate Jeopardy which was identified on 9/26/24 at 5:45 PM. An IJ summary tool was provided to the facility on [DATE]. The facility submitted a draft of their plan to remove the immediacy on 9/26/24 at 8:36 PM, and it was not accepted. The facility submitted a second draft of their plan to remove the immediacy on 9/26/24 at 9:30 PM, and it was not accepted. …
D · No harm, potential for more than minimal, isolatedAugust 28, 2026
Based on observation, staff interviews, and documentation review, it was determined that facility staff failed to keep treatment carts locked when unattended and discard expired medications/biologicals. This was evident on 1 of 4 nursing hallways observed during random observations made during a complaint survey. The findings include: On 8/27/26 at 2:12 PM observation was made on the 500-hallway nursing unit of an unlocked and unattended treatment cart sitting in the hallway outside of room [ROOM NUMBER]. The surveyor was able to open the drawers in the treatment cart and observed scissors in the top drawer along with a 100 ml bottle of NSS (normal saline solution) 0.9%, Lot #251111093, that was one third of the way full. The bottle was not dated when opened. …
B · No harm, potential for minimal, patternApril 29, 2019
Based on surveyor observation and interviews with the facility staff, it was determined that the facility staff failed to discard expired medications timely. This finding was evident for 1 of 2 medication rooms observed during the survey. The findings include:
On 04-26-19 at 2:30 PM, surveyor tour of the third floor medication room was done with the third floor unit manager. The following expired medications were found in the medication room:
1. Two 8 oz bottles of Advanced Formula Cerovite liquid (lot # 615) with an expiration date of 12/18 (December (YEAR)) as house stock.
2. One 8 oz bottle of [MEDICATION NAME] 4% solution with an expiration date of 2-20-2018 for resident # 69.
3. …
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