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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in
the facility were stored and labeled in accordance with currently accepted professional standards, included
expirations dates when applicable and ensured that no expired medication were available for use in 2 out of
3 medication carts observed.
Findings:
An observation on [DATE] at 9:48 AM of Hallway 100's medication cart revealed the following: Xylocaine
1% 20 ML (Milliliter) multi dose vial showed no documentation of the date opened, Humulin R Insulin
opened on [DATE] and expired on [DATE], Levemir Flex Pen showed no documentation of the date opened,
another Xylocaine 1% 20 ML multi dose vial showed documentation that it was opened [DATE], Debrox ear
drops showed no documentation of the date opened, and Neomycin-Polym eye drops showed no
documentation of the date opened. Review of the narcotic drawer revealed one medication card of
Tramadol 50 MG (Milligram) with (60) tablets with a remaining that expired 1/22 and one medication card of
Tramadol 50 MG with a remaining count of 29 tablets that expired [DATE].
During an interview on [DATE] beginning at 10:07 AM, Staff A Licensed Practical Nurse (LPN) stated, I do
not know why the Insulins are in the drawer with no opened or expired dates. I do not know why the
Xylocaine is opened without the date that the Xylocaine was opened or why the one Xylocaine was opened
for more than 30 days. Insulin and Xylocaine is only good for 30 days after opening. Insulin, eye drops, and
the multi dose vials are all supposed to be dated. I am not sure why the ear drops, and the eye drops do not
show the date they were opened. I don't know why the Tramadol in the narcotics drawer is expired.
An observation on [DATE] at 10:15 AM of Hallway 200's medication cart revealed the following: Xylocaine
1% multi dose vial 20 ML showed no documentation of open date, Humulin N Insulin showed an opened
date of [DATE] with expiration date of [DATE], and Basaglar Insulin showed no documentation of the date
opened.
During an interview on [DATE] at 10:30 AM Staff B, LPN stated, I don't know why the Xylocaine is opened
with no date opened on the box or the vial. The Basaglar pen does not have a date opened. The Humulin N
Insulin is past the expiration date. Insulin and multi dose vials should show the date opened.
During an interview on [DATE] at 8:20 AM the Director of Nursing (DON) stated, On each nursing
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105963
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105963
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lafayette Nursing and Rehabilitation Center
512 W Main St
Mayo, FL 32066
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
medication cart there is a sheet [titled Expiration Date and Expiration Dating of Common Pharmaceuticals]
to show the nursing staff when things like Insulin, eye drops, and ear drops expire. Multi dose vials of
medications are only good for 30 days after opening. The nursing staff are supposed to check for expiration
dates.
Review of the document titled Expiration Date reads, Brand: Humulin N, Vial Exp (expires): 28, Brand:
Humulin R, Vial Exp: 28, Brand: Lantus, Vial Exp: 28, Brand: Levemir, Pen Exp: 42.
Review of the document titled Expiration Dating of Common Pharmaceuticals reads Product: Insulin vials
unrefrigerated: Expiration Guideline: 28 days either opened or unopened; or per manufacturer guidelines
and Multi dose injectable vials with preservatives: Expiration Guideline: 28 days from date opened.
Review of the facility policy titled Storage of Medications with a revised date of [DATE] and last reviewed on
[DATE] read Policy Statement. The facility policy shall store all drugs and biologicals in a safe, secure and
orderly manner. Policy Interpretation and Implementation #4. The facility shall not use discontinued,
outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy
or destroyed upon discovery.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105963
If continuation sheet
Page 2 of 2
