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.
C # NJ 843
Based on interview and review of medical records including facility surveillance camera footage for 9/4/22 and 9/5/22, it was determined that 2 of 3 facility staff (Licensed Practical Nurse [LPN #1] and Registered Nurse [RN #1]) on the 4th floor South unit, failed to ensure that medications which could cause significant harm if ingested, were stored, secured, in locked compartments and inaccessible to high-risk residents with wandering behaviors. The facility also failed to follow their policies Administering Medications, Medication Storage, and General Medication Administration Guidelines of Oral Preparations. This deficient practice was identified for 1 of 3 sampled residents (Resident #1). …
D · No harm, potential for more than minimal, isolatedAugust 20, 2026
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain appropriate environmental controls for the storage of medications. The deficient practice was identified for 1 of 2 (Evergreen) medication rooms observed during the Medication Storage Task. The deficient practice was evidenced by the following: On [DATE] at 09:31 AM, the surveyor observed the Evergreen Medication Room. The surveyor was accompanied by the Unit Manager Licensed Practical Nurse, who unlocked the medication room door for the surveyor. At that time, the surveyor observed two plastic bags filled with medications that belonged to an unsampled, discharged resident. The resident was discharged in June of 2026. …
B · No harm, potential for minimal, patternDecember 16, 2021
Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure that suction equipment supplies, nasal cannula, and saline solution that all expired in 2020 and 2021 respectively were removed from active inventory in 3 of 3 emergency carts. This deficient practice was evidenced by the following:
On [DATE] at 1:16 PM, the surveyor observed an emergency cart located on the third floor adjacent to the nurse's station. …
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