The incident occurred at Maria Regina Rehabilitation and Nursing during a January 28 federal inspection. Resident #31, who has dry eye syndrome and cataracts, was observed taking Refresh Liquigel eye drops from an unlocked cup and applying them to their right eye at 10:34 AM.
The drops had expired.
The resident told inspectors that nurses had given them the Refresh Liquigel to self-administer. But the facility's medication nurse, Licensed Practical Nurse #5, said they weren't aware the resident had any medications in their room.
"The resident did not have a physician's order to self-administer any medication and these medications should not be stored in the resident's room, especially the expired medication," the nurse told inspectors.
The plastic cup contained two bottles of Refresh Liquigel eye drops and two bottles of Systane Lubricant eye ointment. Federal regulations require all medications to be stored in locked compartments when not in use.
Resident #31's medical records showed no assessment or care plan allowing them to self-administer medications. Their cognitive abilities were intact, with a Brief Interview for Mental Status score of 15, indicating they could understand instructions.
The resident had a physician's order for Systane Nighttime eye ointment to both eyes at bedtime, last renewed in January. But there was no order for the Refresh Liquigel drops they were using.
Licensed Practical Nurse #4 confirmed the violation during a separate interview. "Resident #31 should not have had any medications including any expired medication in their room because they do not have a Physician's order to self-administer medication," the nurse said.
The facility's own policy, dated from their medication storage guidelines, explicitly prohibits using "discontinued, outdated, or deteriorated drugs or biologicals." The policy requires medications to be stored in locked cabinets, drawers, or carts, with each resident's medications assigned to individual compartments to prevent mixing.
The facility's pharmacist explained the safety concerns during an interview with inspectors. "Refresh eye drops should discarded after the manufacturer's expiration date," the pharmacist said. "They do not recommend using any medication past the expiration date because the medication may become less effective."
Director of Nursing Services acknowledged the multiple violations when questioned by inspectors. The director confirmed that Resident #31 "should not have had any eye drops stored in the resident's room without an evaluation and a physician's order to self-administer the medication."
The director added that "the resident should not have had access to any expired medication."
The resident's comprehensive care plan for visual deficit, dated earlier in their stay, included interventions for ophthalmology and optometry consults and encouragement to ask for assistance as needed. It made no mention of self-medication.
Maria Regina Rehabilitation and Nursing received a citation for failing to ensure drugs and biologicals were stored in locked compartments under proper temperature controls. The violation was classified as causing minimal harm with potential for actual harm, affecting few residents.
The 335-bed facility on Brentwood Road has faced previous federal scrutiny for medication management issues. This latest violation demonstrates ongoing problems with basic medication safety protocols that put vulnerable residents at risk.
Federal regulations exist specifically to prevent residents from accessing medications without proper medical supervision. Expired medications can lose effectiveness or potentially cause harm, particularly for residents with complex medical conditions requiring multiple treatments.
The incident raises questions about how the resident obtained the medications initially and why nursing staff weren't aware of their presence. The facility's medication tracking systems appear to have failed at multiple levels, from initial distribution through ongoing monitoring.
Resident #31 continues to receive treatment for dry eye syndrome and cataracts. Their case illustrates how seemingly minor medication storage violations can expose residents to unnecessary health risks in facilities responsible for their comprehensive care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maria Regina Rehabilitation and Nursing from 2025-01-28 including all violations, facility responses, and corrective action plans.
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