Federal inspectors found nystatin powder stored in a basket alongside a resident's shampoo at Paradigm at the Prairies during a November complaint investigation. The antifungal medication was easily accessible to any resident who entered the room.
The Director of Nursing told inspectors that confused residents might ingest the medication and suffer adverse reactions, especially if someone allergic to the drug accidentally consumed it. She said she wasn't sure why nobody had noticed the nystatin powder sitting in the room.
Zinc oxide, another medicated ointment, was also found improperly stored in resident areas rather than secured in medication carts as required by facility policy.
"The resident might misuse it or other residents might get a hold of it and put them in their mouth or eyes," the Director of Nursing explained to inspectors.
The Assistant Director of Nursing said the medications should never be stored in residents' rooms because patients might administer or use them incorrectly, resulting in adverse reactions. She emphasized that medicated ointments contain chemicals that could be toxic when consumed.
Both nursing supervisors admitted they weren't sure how staff had missed seeing the nystatin powder sitting openly in the resident's personal items.
"The expectation was for the staff to be observant to see if there were medications inside the residents' room and to be mindful not to leave the medicated ointment inside the residents' rooms," the Assistant Director of Nursing told inspectors.
The facility's Administrator acknowledged that no medications should ever be left in resident rooms to prevent accidental consumption that could result in allergic reactions, stomach upset, and skin irritations.
The violation occurred despite the nursing home's own written policy stating that only authorized medical and licensed nursing staff should administer medications ordered by physicians. The policy, revised in June 2019, makes no provision for storing prescription medications in resident rooms where untrained individuals could access them.
All three facility leaders promised inspectors they would coordinate in-service training to educate staff about proper medication storage. The Director of Nursing said she would specifically ensure no medications remained accessible to residents throughout the facility.
The incident highlights ongoing medication safety concerns in nursing homes, where residents with dementia and cognitive impairment may not understand the dangers of consuming unfamiliar substances they encounter in their living spaces.
Federal regulations require nursing homes to store all medications securely to prevent unauthorized access. Prescription antifungal powders like nystatin can cause serious reactions if consumed by individuals who are allergic to the medication or who take it in inappropriate doses.
The inspection occurred following a complaint to state health officials about conditions at the 120-bed facility. Inspectors classified the medication storage violation as having potential for minimal harm affecting few residents.
However, the nursing supervisors' own statements to inspectors revealed the serious risks posed by the improper storage. Confused residents could easily mistake the white nystatin powder for a food product or personal care item, leading to accidental ingestion.
The facility operates under a policy requiring all medications to remain under the control of licensed medical staff, yet basic oversight failures allowed prescription drugs to sit openly in resident living areas for an unknown period before discovery.
Staff members who regularly entered the resident's room for care activities apparently failed to notice or report the improperly stored medications, raising questions about the effectiveness of the facility's medication monitoring procedures.
The Administrator's acknowledgment that accidental consumption could cause multiple types of adverse reactions underscored the potential severity of the violation, even though inspectors determined actual harm had not yet occurred.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Paradigm At the Prairies from 2025-11-18 including all violations, facility responses, and corrective action plans.