Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
observations, interviews and records review, the facility failed to properly label, store and discard expired
medications in a medication cart that serves 21 residents on the second floor. This deficiency has the
potential to affect R12, R18, R76, R37, and 21 residents receiving medications from the second floor, team
two medication cart, in a sample of 30 residents reviewed.
Findings include:
On 01/09/2024 at 9:46am, during review of medication cart on the second-floor team two, with V11
(Registered Nurse-RN), surveyor and V11 observed following expired medications on the cart as follows:
R37
Latanoprost 0.005 % eye drops -No opened or expiration date on the medication.
R12
Lantus 100 units /ml (milliliter) insulin vial - Opened date 11/29/2023. Expiration date noted on the
medication bottle-12/27/2023
Humalog 100 units/ml insulin vial - Opened date 11/27/2023. Expiration date: 12/27/2023.
R18
Humalog 100 units/ml insulin vial - Opened vial, no date when opened or when medication will expire.
R76
Humalog 100 units/ml insulin vial - Opened date 11/29/2023. Expiration date: 12/27/2023.
House Stock medications:
Vitamin E 180mg (milligrams) (400iu) bottle -expiration date-11/23
(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 3
Event ID:
145796
Printed: 05/15/2026
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
145796
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Balmoral Home
2055 West Balmoral Avenue
Chicago, IL 60625
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
Sodium Bicarbonate 10gr (grams) (650mg). there was no cap covering the bottle, medications observed
exposed.
V11 said that insulin, after it is opened is good for 28 days, and after 28 days it should be discarded
because it might no longer be effective, and residents blood sugar levels might not be properly controlled
given the expired insulin, and this can have adverse effects on the residents who receive the expired
insulin. V11 stated there were 21 residents receiving medications from the second-floor team two cart. V11
further said that all medications should be stored in the medication cart with the cap on to prevent
contamination and to preserve medication potency and prevent the risk of the medication getting mixed
with other medications.
R76 current face sheet documents R76 is a [AGE] year-old individual admitted to the facility on [DATE], and
medical diagnosis include but not limited to: Diabetes Mellitus, Paranoid Schizophrenia.
R76 Physician Order Sheet dated 11/09/21 documents:
-Humalog Subcutaneously 100U/ML insulin three times a day per sliding scale before meals: Blood sugar
below 180=0 units, 181-220=2 units, 221-260=4 units, 261-300 units=6 units, 301-350=8 units, 351-400
=10 units.
R18 current face sheet documents R18 is a [AGE] year-old individual admitted to the facility on [DATE],
medical diagnosis includes but not limited to: Diabetes Mellitus, Heart failure, Schizophrenia.
R18 Physician Order Sheet dated 12/06/23 documents:
-Humalog 100U/ML Insulin per sliding scale three times a day per: 0-200 =0units, 201-250=3 units,
251-300=5 units, 301-350=7 units, 351-400=10 units Blood glucose greater than 400 =15 units and call MD
(Medical Doctor).
R12 current face sheet documents R12 is a [AGE] year-old individual admitted to the facility on [DATE],
medical diagnosis includes but not limited to: Type 1 Diabetes Mellitus without complications, Unspecified
Glaucoma, Paranoid Schizophrenia.
R12 Physician Order Sheet dated 02/11/19 documents:
-Humalog 100U/ML vile (Insulin Lispro). Inject 10 units subcutaneously twice a day before meals. Rotated
site. DX (diagnosis): Diabetes Mellitus.
R37's current face sheet documents R37 is a [AGE] year-old individual admitted to the facility on [DATE].
Medical Diagnosis include but not limited to Type 2 Diabetes Mellitus without complication, Unspecified
Glaucoma, Muscle Weakness.
R37's current POS dated 12/29/20 documents:
Latanoprost 0.005% eye drops (for Xalatan 0.005%Eye DR) Instill 1 drop into each wye daily DX:
Glaucoma.
On 1/14/2023 at 11:09 V2 (Director of Nursing) said if medications are expired, they should be
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145796
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
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
145796
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Balmoral Home
2055 West Balmoral Avenue
Chicago, IL 60625
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
discarded because it is not good practice to administer expired medication. V2 further said when
medication is expired, it will not be therapeutic for the resident and can have adverse effects on the
residents. V2 said insulin should be labeled with the date it was opened and the date it will expire, and once
insulin is opened, it is only good for 28 days, and should be discarded after 28 days.
Residents Affected - Some
The facility's Medication Administration Policy titled: Expired Medications, no date, documents:
Medications nearing expiration will be flagged, and appropriate measures will be taken to avoid
administration of expired drugs.
Expired medications will be clearly marked with a visible label indicating their expiration date.
-Nursing staff will be trained to identify and report any expired medications promptly.
-Expired medications will be disposed of following local and federal regulations for pharmaceutical waste
disposal.
The facility's Policy, titled: Insulin Medication and expired Insulin Management, no date, documents:
-Regular checks of insulin expiration dates will be conducted by designated healthcare staff.
-Expired insulin must not be used for the resident administration.
-Expired insulin will be promptly removed from the storage area and properly disposed of following
established waste disposal guidelines.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145796
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F761 - Labeling of Drugs and Biologicals
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.
FAQ · About this visit
Common questions about this visit
What happened during the January 12, 2024 survey of BALMORAL HOME?
This was a inspection survey of BALMORAL HOME on January 12, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BALMORAL HOME on January 12, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.