The resident, known in the report as Resident #48, told inspectors on September 8 that "nurses often left her medication on the bedside table." Two days later, inspectors found a bottle of fluticasone propionate nasal suspension sitting unattended on the woman's bedside table while she was out of her room.
The 71-bed facility had no physician's order allowing the resident to self-administer medications or keep them at bedside. Licensed Practical Nurse #704, who had administered the resident's morning medications that day, confirmed to inspectors that she left the nasal spray on the bedside table and acknowledged the resident lacked authorization for self-medication.
Resident #48 has been living at Windsor Lane since February 12, 2025. Her medical conditions include morbid obesity, chronic respiratory failure with hypoxia, and Type I diabetes. A July assessment showed she had intact cognition but required moderate assistance with daily activities.
The resident's care plan, dating back to March 2023, documented her chronic obstructive pulmonary disease, congestive heart failure, and history of respiratory failure. Her treatment plan included monitoring for breathing difficulties and administering aerosol medications as ordered.
Her physician had prescribed the fluticasone propionate nasal suspension on February 17, 2024 — two sprays in both nostrils once daily for allergies. The medication administration record showed she received the drug during morning medication rounds on September 10.
But when inspectors arrived at 8:58 that morning, they found the prescription bottle and its box sitting openly on her bedside table. The resident's name appeared on the packaging, confirming it belonged to her.
The nurse who left the medication there admitted the violation. LPN #704 told inspectors she had administered the resident's morning medications and "confirmed the fluticasone propionate was left on the bedside table." She also "confirmed Resident #48 did not have a physician's order to self-administer medication or for medications to be left at bedside."
Windsor Lane's own policy, dated March 20, 2018, explicitly states that residents can only self-administer medications "when specifically authorized by the attending physician and in accordance with procedures for self-administration of medication."
The medication storage violation represented one of three residents inspectors reviewed during their investigation. Federal regulations require all drugs and biologicals to be stored in locked compartments to prevent unauthorized access and potential harm.
Leaving prescription medications unattended creates multiple risks. Other residents or visitors could accidentally take the wrong medication. The intended resident might take an incorrect dose without supervision. Environmental factors like temperature or contamination could compromise the medication's effectiveness.
The fluticasone propionate that inspectors found is a corticosteroid nasal spray commonly prescribed for allergies and inflammation. While not a controlled substance, it requires proper medical supervision like any prescription medication.
This violation occurred despite the resident's intact mental capacity. Federal inspectors noted that Resident #48 had full cognitive abilities, making the unauthorized medication storage even more concerning since facility policy specifically required physician authorization for self-administration.
The inspection was conducted as part of complaint investigations numbered 1357285 and 1357196, suggesting multiple concerns had been raised about the facility's practices.
Windsor Lane Healthcare Center sits at 355 Windsor Lane in Gibsonburg, a small community in northwest Ohio. The facility serves 71 residents, many with complex medical conditions requiring careful medication management and supervision.
Federal inspectors classified this as a minimal harm violation affecting few residents. However, the routine nature of the practice — with the resident telling inspectors that nurses "often" left medication on her table — suggests the problem extended beyond a single incident.
The case highlights how seemingly minor policy violations can create safety risks in nursing home settings. When staff bypass established medication protocols, even with non-controlled substances, they potentially expose vulnerable residents to harm through improper dosing, contamination, or accidental ingestion by others.
Resident #48 continues to live at Windsor Lane, dependent on staff to properly manage her complex medication regimen for diabetes, respiratory conditions, and other serious health issues.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Lane Healthcare Center from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
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