On January 29, inspectors documented four separate incidents across two nursing units where staff violated the facility's own medication security policy. The violations occurred within a 21-minute window between 10:42 a.m. and 11:03 a.m.
Licensed Practical Nurse #5 left their cart unlocked in the hallway on the third floor north unit. Unit Manager #2 walked past the abandoned cart at 10:45 a.m., noticed it was unsecured, and locked both the cart and computer screen before walking away.
"I was not aware that I left it unlocked," the nurse told inspectors minutes later, acknowledging the cart should have been secured.
Four minutes later on the same unit, Licensed Practical Nurse #4 left another medication cart unlocked near the nurse's station while administering medication to a resident in the dining area. The nurse returned to find inspectors waiting.
"I thought that the cart was locked because I normally do lock the cart," the nurse said, admitting they should have secured it before walking away.
The pattern repeated on the second floor south unit. Licensed Practical Nurse #3 left their cart unlocked in front of a resident's room with the computer screen displaying another resident's medication administration record. The nurse was inside the room with a patient when inspectors arrived.
"I was busy and forgot to lock the cart, but I typically do lock the cart when I am not near the cart," the nurse explained, acknowledging the violation.
Three minutes later, Licensed Practical Nurse #2 was taking vital signs with a resident on the right side of the nurse's station while their medication cart sat unlocked on the left side.
"I did not lock the medication cart, but the medication cart should have been locked," that nurse admitted.
The facility's medication storage policy, dated December 2020, explicitly states that medications and biologicals must be "stored safely, securely, and properly" and remain "accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication."
Federal regulations require all drugs and biologicals to be stored in locked compartments, with controlled substances kept in separately locked compartments. The requirement exists because unsecured medications pose risks of theft, diversion, or accidental ingestion by residents with dementia or cognitive impairment.
Each violation occurred during routine medication administration rounds when nurses temporarily left their carts to provide care in resident rooms or common areas. The inspection found no privacy screens on computer displays, meaning medication records remained visible to anyone passing by the unattended carts.
The complaint-driven inspection at St Cabrini resulted in a citation for minimal harm with few residents affected. However, the systematic nature of the violations across multiple units and staff members suggests broader compliance issues with medication security protocols.
St Cabrini Nursing Home operates as a 240-bed facility in Westchester County. The January inspection focused specifically on medication management practices following an undisclosed complaint to federal regulators.
Licensed practical nurses typically manage medication carts during scheduled administration times, moving between resident rooms and common areas throughout their shifts. Each cart contains both routine medications and controlled substances that require heightened security measures under federal law.
The four nurses involved in the violations acknowledged their mistakes during inspector interviews, with each stating they normally follow proper locking procedures. However, the concentration of security failures within a single morning raised questions about staff training and supervision on medication handling protocols.
Federal inspectors noted that while no medications appeared to have been accessed inappropriately, the repeated failures to secure carts created opportunities for unauthorized access that could have resulted in more serious consequences for resident safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Cabrini Nursing Home from 2026-01-29 including all violations, facility responses, and corrective action plans.