Stay Ahead of Compliance with Monthly Citation Updates


In your State Survey window and need a snapshot of your risks?

Survey Preparedness Report

One Time Fee
$79
  • Last 12 months of citation data in one tailored report
  • Pinpoint the tags driving penalties in facilities like yours
  • Jump to regulations and pathways used by surveyors
  • Access to your report within 2 hours of purchase
  • Easily share it with your team - no registration needed
Get Your Report Now →

Monthly citation updates straight to your inbox for ongoing preparation?

Monthly Citation Reports

$18.90 per month
  • Latest citation updates delivered monthly to your email
  • Citations organized by compliance areas
  • Shared automatically with your team, by area
  • Customizable for your state(s) of interest
  • Direct links to CMS documentation relevant parts
Learn more →

Save Hours of Work with AI-Powered Plan of Correction Writer


One-Time Fee

$49 per Plan of Correction
Volume discounts available – save up to 20%
  • Quickly search for approved POC from other facilities
  • Instant access
  • Intuitive interface
  • No recurring fees
  • Save hours of work
F0658
E

Failure to Administer Medications Timely Due to Staffing Shortages

Fortuna, California Survey Completed on 04-10-2025

Penalty

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Licensed Nurses failed to administer medications to residents according to physician orders, resulting in multiple instances of late medication administration for two residents. For one resident with diagnoses including palliative care and malignant neoplasm of the skin, medications such as propranolol, methadone, and gabapentin were documented as being given significantly later than scheduled, with delays ranging from over an hour to more than four hours. Another resident with epilepsy experienced late administration of medications including ropinirole, levetiracetam, and aspirin, with delays of over an hour past the scheduled times. The facility's policy allows for medications to be administered within one hour before or after the scheduled time, but these instances exceeded that window. Interviews with nursing staff and the Director of Nursing revealed that the late administration was due to severe staffing shortages, with each nurse assigned to care for 28 to 34 residents per shift. Staff reported that the high number of resident assignments made it impossible to administer all medications on time. The Director of Nursing confirmed that the facility had not met state staffing requirements during the relevant periods. One resident reported experiencing anxiety and discomfort due to the late administration of medications. The facility's own documentation and staff interviews confirmed the pattern of late medication administration and the underlying staffing issues.

An unhandled error has occurred. Reload 🗙