River Brook Healthcare: Expired Drug Disposal Failures - GA
That was what inspectors found on the morning of September 27, 2025.
The box was not a one-time oversight. It was the system.
When inspectors spoke with Registered Nurse AA at 9:12 that morning, she explained how it worked. Expired and discharged medications get pulled from the medication carts and dropped into the box in the medication room. Once a month, she empties the box by transferring medications into smaller boxes. She gives those smaller boxes to the Director of Nursing. She does not label them. She does not log what goes into them. She said she doesn't know exactly what the pharmacist does with them after that, because she is not part of that process.
The Director of Nursing filled in the next step. The pharmacist comes in monthly, she told inspectors at 9:35 that morning, scans the medications, and generates a return slip. But the pharmacist does not take the medications with her when she leaves. Someone else comes to pick them up, the DON said, within one to two weeks, sometimes sooner. Until that pickup happens, the medications stay in the box in the medication room.
The DON confirmed she does not log the discharged or expired medications either. There is, she said, no accounting for what is in the box until the pharmacist arrives to scan it. Nothing is recorded when a medication is pulled from a cart and placed in the box. Nothing is recorded when the nurse transfers them into smaller boxes. Nothing is recorded when those boxes are handed off. The drugs simply accumulate, untracked, in an open container in a room where medications are stored and administered.
Licensed Practical Nurse BB described the same process when inspectors spoke with her the following morning. When she has an expired or discontinued medication, she pulls it from the cart and puts it in the box. She does not log it. She does not label it. She said she does not know when, or whether, the DON scans what she has placed there.
The facility's own pharmacy policy manual, last revised in July 2024, laid out three acceptable methods for handling medications headed for destruction. Under the first, medications are removed from their containers and rendered unusable before disposal. Under the second, sealed boxes are taped shut, labeled as medication for destruction, locked away, and picked up by a licensed waste disposal company. Under the third, commercially approved drug disposal kits are used.
The box inspectors found on September 27 met none of those criteria. It was not sealed. It was not labeled. It was not locked. Its contents were not recorded anywhere in the facility.
The facility's medication administration policy, dated January 2025, states that medication destruction follows pharmacy policy, and that the consultant pharmacist and Director of Nursing are responsible for following it.
The Director of Nursing is one of the two people named in that policy. She told inspectors she does not log the medications and that there is no record of what is in the box until the pharmacist arrives, which happens once a month.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting many residents. Inspectors noted the facility's own policy pointed to a pharmacy policy manual that required specific handling procedures, and that none of those procedures were being followed in practice.
What the facility had instead was a box. Open, unlabeled, unmonitored, and refilled each month by nurses who had been told, in some form or another, that someone else downstream would sort it out.
Nobody logged what went in. Nobody logged what came out. For the weeks between pharmacist visits, there was no record that the medications in that box had ever existed at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Brook Healthcare Center from 2025-09-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
RIVER BROOK HEALTHCARE CENTER in HOMERVILLE, GA was cited for violations during a health inspection on September 28, 2025.
That was what inspectors found on the morning of September 27, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.