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 record review of the facility medication storage policy, the manufacturer's instructions for use for
insulin, interviews and observations the facility failed to ensure medications were appropriately labeled and
dated once opened. This affected nine residents (Residents #14, #21, #27, #47, #48, #49, #55, #256 and
#257) on two of two medication carts observed in the facility. The facility census was 59.
Findings included:
Observation on 04/20/22 at 4:02 P.M. of the 300-hall medication storage cart revealed one Humalog (insulin
) pen for Resident #55 was opened without a date on it of when it was opened and there was no expiration
date per manufacturer's guidelines on it. An Aprida (insulin) pen for Resident #256 was opened and without
a date it was opened and without an expiration date per manufacturer's guidelines on it. One bottle of
Dorzolamide HCL opthalmic solution and Timolol Maleate ophthalmic solution for Resident #257 were both
open and without a date of when those were opened and without a use by date. At the time of the
observation, LPN #520 confirmed the findings in the medication storage cart.
Observation on 04/20/22 at 4:20 P.M. in the medication storage refrigerator revealed one bottle of liquid
Pantoprazole ( a medication for stomach upset ) for Resident #49 was found open with an expiration date of
07/08/21. In the medication storage refridgerator was one open bottle of acidophilus probiotic without a
resident name on it and with an expiration date of Jan. 2022. At the time of the observation, LPN #520
confirmed the findings in the medication storage room.
Observation on 04/20/22 at 4:40 P.M. of the medication storage cart for the 100-hall revealed multiple
medications without a date opened and expiration date marked on them. The findings were as followed:
•
one tube of Erythromycin ointment and one five milliliter bottle of Prednisolone suspension for Resident #14
•
one tube of Diclofenac gel for Resident #21
•
(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:
366434
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
366434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/21/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hudson Springs Nursing and Rehab
5000 Sowul Boulevard
Stow, OH 44224
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
one bottle of Thera Tears opthalmic solution, one bottle of Latanoprost solution, and one bottle of
Budesonide and Formoterol Fumarate Dihydrate inhalation aerosol for Resident #27.
Level of Harm - Minimal harm
or potential for actual harm
•
Residents Affected - Some
one tube of Brimonidine Tartrate ophthalmic solution for Resident #47.
•
one tube of Diclofenac gel and one bottle of Moxifloxacin solution HCL for Resident #48.
At the time of the above observations, Registered Nurse (RN) #503 confirmed all the findings.
Review of the facility policy titled Medication Storage in The Facility Policy, dated 05/2020, revealed when
the original containers of all medications were first opened, they shall be dated with the date opened by the
nurse and an expiration date shall also be marked by the nurse. Certain medications such as multi-dose
injectable vials, opthalmics (eye drops) once opened required an expiration date shorter than the
manufacturers use by date to ensure purity and potency. For opthalmics a use by date of 60 days from the
date opened or manufacturer's use by date if less than 60 days will be marked on the container by the
nurse. For insulin the nurse should follow the manufacturer's instructions. For all other medications a use by
date of 60 days from the date opened or manufacturer's use by date if less than 60 days will be marked on
the container by the nurse.
Review of the manufacturer's Instructions for Use of Humalog insulin pen as indicated at internet address
pil.lilly.com indicated the Humalog pen must be discarded after 28 days of opening even if there is insulin
left in it.
Review of the manufacturer's Prescribing Information for Aprida insulin pen as indicated at internet address
products.sanofi.us indicated the Aprida pen must be discarded after 28 days of first use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366434
If continuation sheet
Page 2 of 2
