Health inspection·July 21, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation interviews and policy review, the facility did not ensure medications were stored and labeled appropriately in three medication carts (Split back, East front and [NAME] front) of three medication carts observed. Findings included: 1. An observation on 7/21/2025 at 2:25 P.M. of the Split Back Cart Medication Cart revealed an undated used bottle of Latanoprost eye drops, two undated Breo Inhalers and an undated Combivent inhaler. The boxes containing the Breo inhalers were labeled expires six weeks after opening and the Combivent inhaler was labeled expires three months after opening. The boxes did not show an opening date.An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 7/21/2025 at 2:32 P.M. She stated if she found medications that were not labeled in the medication cart, she would discuss it with the shift supervisor. She stated she never discards medications from the medication cart without speaking to a supervisor. The nurse placed all the undated medications back into the medication cart. Staff B, LPN stated it was her second day working at the facility and she did know what pharmacy they use. 2. An observation on 7/21/2025 at 2:37 P.M. of the East Front Medication Cart revealed a bottle of Ibuprofen which was opened. There was no date to indicate when the bottle was opened.An interview was conducted with Staff A, LPN on 7/21/2025 at 2:43 P.M. She stated the medication was probably opened today. Staff A proceeded to label the medication with a date of 7/21/2025. She stated she did not give this medication to any residents today. 3. An observation on 7/21/2025 at 3:00 P.M. of the [NAME] Front Medication Cart revealed an undated empty bottle of Omeprazole which was in the top drawer of the cart, an undated used bottle of Latanoprost eye drops, two undated used bottles of Loteprednol eye drops, an undated used bottle of Timolol eye drops and an undated used Breo Inhaler. The box the inhaler was stored in read, expires six weeks after opening. There was no date to indicate when the bottle was opened.An interview was conducted with the Director of Nursing (DON) on 7/21/2025 at 3:08 P.M. She said all medications should be labeled with the date it was opened and the expiration date. She said the inhalers always expire before the printed manufacturer's date on the inhaler box, if they are opened. She stated the facility had a lot of agency staff at this time, but they were trying to recruit permanent staff. The DON stated her expectations were for the nurses to follow the pharmacy's recommended expiration dates.A review of the facility policy titled Medication Labeling and Storage reviewed on 3/2023 revealed, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The policy and interpretation and Implementation section titled, Medication Labeling showed: 1. Labeling of the medications and biological dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum: d: expiration date and g: appropriate instructions and precautions. 8: If the medication containers have missing, incomplete, improper or Page 1 of 2 105712 105712 07/21/2025 Alhambra Healthcare & Rehabilitation Center 7501 38th Ave N Saint Petersburg, FL 33710

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. A review of the facility policy titled, Pharmscript Storage of Medications revised on 8/2024 showed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The policy's General Guidance, reads, 8: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. The policy's Expiration Date (Beyond-Use Dating) reads, 3: Certain medications or package types, such as IV (Intravenous) solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency. 5: When the manufacturer has specified a useable duration after opening (i.e. beyond use date, the nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating; b: If a vial or container is found without a stated date opened, the date opened will automatically default to the date dispensed and the expiration date will be calculated accordingly. 6: The nurse will check the expiration date of each medication before administering it. 8: All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. 105712 Page 2 of 2