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F0658
D

Failure to Administer Scheduled Medications Timely

Oakland, California Survey Completed on 09-23-2025

Penalty

No penalty information released
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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

A deficiency occurred when a resident with multiple diagnoses, including major depressive disorder, anxiety disorder, and essential hypertension, did not receive scheduled medications in a timely manner. The resident reported having to ask repeatedly for medications, and new nursing staff were unfamiliar with the medication administration routine. Observation confirmed that the resident had not received morning medications, including carvedilol, aspirin, ferrous sulfate, multivitamins, and vitamin C, as scheduled. The registered nurse on duty admitted to missing the scheduled administration time due to being new and unfamiliar with the shift routine. Review of the Medication Administration Record (MAR) showed that the resident's blood pressure readings were elevated on several occasions, and that medications were not administered within the facility's required two-hour window. The Director of Staff Development confirmed that delays in medication administration could result in medical conditions not being addressed promptly. Facility policy requires medications to be administered safely, accurately, and in a timely manner, adhering to the six rights of medication administration, which was not followed in this instance.

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