Federal inspectors documented widespread medication safety failures at Windsor Convalescent Center of North Long Beach during a June 28 inspection. The facility stored expired vitamins and supplements for up to four months past their expiration dates while improperly handling critical medications for diabetes, seizures, and eye conditions.
In the medication room, inspectors found four bottles of cranberry tablets that expired in May 2024, vitamin B12 supplements that expired in February and March 2024, and calcium plus vitamin D3 tablets that expired in April 2024. One bottle of the constipation medication bisacodyl had been expired since March.
The Assistant Director of Nursing told inspectors the facility "missed to remove expired bottles of medications and dietary supplements." She acknowledged that residents could suffer health complications from receiving expired medications that become ineffective or toxic.
Critical Medications Stored Improperly
Inspectors found more serious violations involving medications requiring specific storage conditions. A bottle of latanoprost eye drops for Resident 46 was discovered in a medication cart with no opened date or expiration date marked, despite manufacturer requirements that unopened bottles be refrigerated and opened bottles be discarded after six weeks at room temperature.
Licensed Vocational Nurse 3 admitted she "was not sure why the medication was in the medication cart" and stated the eye drops were "not safe to be administered because it was not known when it was removed from the refrigerator." She warned that Resident 46 could suffer blurred vision, eye irritation, and other complications from improperly stored drops.
The Director of Nursing initially thought latanoprost could be stored at room temperature. After checking the package insert during the inspection, she confirmed it should be refrigerated and properly labeled with an opened date.
Insulin and Seizure Drugs at Risk
In another medication cart, inspectors found an unsealed vial of Humulin R insulin for Resident 107 with no opened date. The manufacturer requires insulin vials to be discarded 31 days after opening. The licensed nurse said the vial was "almost full" but couldn't determine how long it had been opened.
Two bottles of gabapentin liquid for seizure patients were stored at room temperature despite requiring refrigeration. One bottle for Resident 22 had been opened since May 27, while another for Resident 104 was opened June 22. Both medications treat seizures and nerve pain.
Licensed Vocational Nurse 4 explained that gabapentin "may lose its effectiveness and safety" when stored improperly. He warned that Resident 22 would face "increased risk for seizures, injury, and hospitalization" if the medication wasn't effective. For Resident 104, who takes gabapentin for both seizures and pain, improper storage could cause agitation from untreated pain and increase seizure risk.
The facility's registered pharmacist confirmed both gabapentin solutions required refrigeration between 36 and 46 degrees Fahrenheit.
Medications Placed Near Urine
The most striking infection control violation occurred when Licensed Vocational Nurse 2 placed her medication tray next to a resident's urinal during pill administration. Inspectors observed the nurse administering twelve medications to Resident 80 while an empty urinal and another urinal containing yellow liquid sat on the bedside table.
The nurse told inspectors that Resident 80 "argued and wanted both urinals on the table" despite being told they should be stored in a holder beside the bed. She said the resident "was really set in his own ways and did not understand the risk of infection."
The Director of Nursing said there was "a risk of cross-contamination, infection and hospitalization for facility staff and residents." She stated the licensed staff should have cleaned the bedside table, emptied the urine, then administered medications.
PPE Removed Incorrectly
During care for a resident requiring enhanced barrier precautions, an Assistant Minimum Data Set Coordinator removed her protective equipment incorrectly. While troubleshooting a feeding pump alarm for Resident 48, who requires isolation precautions due to multi-drug resistant organisms, she removed her gown first, then gloves.
The staff member admitted she "did not doff her PPE properly and was nervous that she forgot the correct way." The Infection Preventionist confirmed staff should remove gloves first, then gowns, to prevent contamination.
Vaccination Records Missing
The facility's infection control problems extended to vaccination tracking. The Infection Preventionist, who started in April 2024, told inspectors she had "no updated list of COVID vaccination status of residents and staff." The last update was completed in March 2024.
Staff vaccination logs showed seven employees with no documentation of their vaccination status. Eleven new hires since April weren't listed on vaccination logs at all. The resident vaccination log contained no information about any resident's COVID-19 vaccination status.
Antibiotic Misuse
Inspectors found the facility prescribed topical antibiotics to three residents without meeting their own criteria for antibiotic use. Residents 12, 47, and 111 received ketoconazole cream and clindamycin solution without documentation showing they met the facility's McGeer criteria, which requires at least three symptoms before starting antibiotic treatment.
The Infection Preventionist stated that prescribing unnecessary antibiotics "puts the resident at high risk to developing resistant to the medication."
Pneumonia Vaccine Not Offered
Resident 112, who has chronic obstructive pulmonary disease, respiratory failure, and a history of pneumonia, was not offered a pneumococcal vaccine despite facility policy requiring the vaccine be offered within five days of admission. The resident was admitted with severe breathing problems and nicotine dependence.
The Infection Preventionist couldn't find any consent forms or documentation that the vaccine was declined. She blamed "miscommunication with admitting licensed nurses" for the oversight.
Quality Improvement Failures
The facility's Quality Assessment and Assurance Committee failed to document implementation of improvement plans for falls, weight management, and wound care. The Assistant Director of Nursing told inspectors she "cannot provide documented evidence QAPI plan was being implemented."
The Director of Nursing admitted they had "a process in place but does not have a list of how many residents had weight variance." Neither could provide evidence their quality improvement plans were actually being carried out.
Kitchen and Equipment Issues
In the kitchen, inspectors found snacks stored in the refrigerator without preparation dates or expiration labels, violating the facility's food storage policy requiring all refrigerated foods to be "covered labelled and dated."
The therapy gym contained a broken adjustable height mat that remained slanted despite attempts to level it with a remote control. The Director of Rehabilitation said the uneven surface "could potentially cause injury or falls to the residents." The equipment was replaced during the inspection, but maintenance staff hadn't routinely checked therapy equipment despite an outside inspection in November 2023.
The facility's medication storage policy, dating from 2008, clearly states that "outdated, contaminated, or deteriorated medications are immediately removed from stock." Yet inspectors found medications expired for months still available for resident use.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Long Beach Post Acute from 2024-06-28 including all violations, facility responses, and corrective action plans.