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F0658
E

Failure to Meet Professional Standards in Medication Administration

Bell Gardens, California Survey Completed on 11-18-2025

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

The facility failed to meet professional standards in the preparation and administration of medications for three of five sampled residents. In one instance, a nurse prepared all of a resident's medications in a single cup and provided them without identifying the medications, despite the resident's request for information. The resident, who had moderate cognitive impairment and required assistance with activities of daily living, reported that nurses never informed her about the medications she was given. Another resident, also with moderate cognitive impairment and dependent on staff for daily activities, received all medications in a plastic cup without explanation from the nurse. The nurse acknowledged that medications should be administered one at a time and that it was the resident's right to know what medications were being given. The resident confirmed that nurses did not explain the medications and expressed that it was his right to be informed about what he was taking. A third resident, who had cognitive impairment and was dependent on staff, received all medications crushed together in a plastic bag and administered via gastrostomy tube. The nurse stated that he typically crushed all medications together and was unaware of the facility's policy regarding separate crushing. The nurse also acknowledged that medications should be administered separately to identify any adverse reactions. The facility's policy indicated that medications should be administered by licensed nurses in accordance with professional standards and that the purpose of medication administration should be explained.

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