The diclofenac sodium gel had expired in November 2023. Inspectors discovered it in September 2025.
Resident 2, who medical records show "had no capacity to understand and make decisions," kept the topical pain medication in the top drawer of her bedside table. Her nursing assessment from her admission date showed she "did not want to self-administer medications."
The facility's own policy requires any unauthorized bedside medications to be "turned over to the nurse in charge for return to the family or responsible party." Staff had left this one untouched.
When inspectors questioned RN 1 about the medication on September 18 at 9:45 a.m., the nurse verified there was no physician's order for the diclofenac gel. The nurse also confirmed no care plan authorized the resident to store medications at her bedside.
"The resident's family member may have brought in the medication," RN 1 told inspectors, adding that the facility would contact the family.
RN 1 explained the medication "needed a physician's order prior to administering" and "should not be left unattended at the resident's bedside because the facility staff would not be able to assess for proper administration of the medication by the resident."
Resident 2 confirmed her family had provided the medication when inspectors interviewed her later that morning. CNA 4 translated the conversation into Vietnamese. When asked when her family brought the medication, Resident 2 said she could not recall.
The Director of Nursing told inspectors that medications could remain at a resident's bedside only with "a physician's order, care plan, and an evaluation to self-administration the medications."
The DON acknowledged a significant safety concern: "Other residents or facility staff could use the medication not intended for their use, if the medication was left unattended at the resident's bedside."
Federal regulations require nursing homes to store all medications in locked compartments and ensure proper labeling according to professional standards. The rules exist to prevent medication errors, unauthorized access, and potential harm to residents.
The violation occurred despite clear documentation in Resident 2's medical record. Her health and physical examination, completed upon admission, established her inability to make informed decisions about her care. Her nursing assessment specifically noted her preference not to self-administer medications.
Facility administrators acknowledged the findings when inspectors presented them on September 18 at 5:12 p.m.
The expired medication represented multiple policy failures. Staff had not conducted proper room checks to identify unauthorized medications. The nursing team had not ensured compliance with the resident's documented inability to self-administer drugs. Management had not implemented their own procedures for removing unauthorized bedside medications.
Diclofenac sodium gel treats arthritis and osteoarthritis pain through topical application. While not a controlled substance, improper use can cause skin irritation, allergic reactions, or interactions with other medications.
The inspection occurred following a complaint to state regulators. Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents.
For Resident 2, the medication's presence created multiple risks. Without medical supervision, she could have applied too much gel, used it on inappropriate body areas, or experienced adverse reactions. Other residents or visitors could have accessed the medication, mistaking it for their own prescriptions.
The facility's failure extended beyond simple policy violations. Staff had multiple opportunities to identify and remove the expired medication during routine care, room cleaning, or medication reviews. Each missed opportunity prolonged the potential for harm.
Resident 2's case illustrates broader challenges in nursing home medication management. Facilities must balance resident autonomy with safety requirements, particularly for individuals with cognitive impairments who cannot safely manage their own medications.
The Administrator and DON's acknowledgment of the findings suggests awareness of the problem. However, the medication had remained in the resident's drawer for nearly two years after expiration, indicating systemic failures in oversight and compliance monitoring.
Federal regulations exist specifically to prevent such situations. When nursing homes fail to follow basic medication storage requirements, they put vulnerable residents at unnecessary risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Huntington Valley Healthcare Center from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
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