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
F0755
E

Failure to Accurately Administer and Document Controlled Medications

Pasadena, California Survey Completed on 11-26-2025

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

The facility failed to administer medications in accordance with physician orders and did not ensure accurate documentation of controlled substances in the Medication Administration Record (MAR) for two residents. For one resident with a history of seizures, dementia, COPD, and bipolar disorder, the MAR indicated that Clonazepam was administered on two occasions. However, a review of the resident's bubble pack and Narcotic and Hypnotic Record showed that the medication was not actually given, as the count of tablets remained unchanged and there was no documentation of administration in the controlled substance log. The nurse had signed the MAR as if the medication was given, but the physical count and records did not support this. Similarly, for another resident with depression, anxiety disorder, and schizophrenia, the MAR showed that Lorazepam was administered, but the bubble pack and Narcotic and Hypnotic Record indicated that the medication was not dispensed, as the tablet count was unchanged and there was no documentation in the controlled substance log. The nurse had again signed the MAR as if the medication was given, but the actual count and records did not match. Both discrepancies were identified during a concurrent review and interview with facility staff, who confirmed that the medications should not have been charted as given if they were not administered. Facility policy requires that controlled medications be documented accurately in both the MAR and the Narcotic and Hypnotic Record, in accordance with federal and state regulations. The Director of Nursing and Assistant Director of Nursing were not aware of the discrepancies until the review, and acknowledged the importance of regular audits to ensure medications are administered and documented correctly. The failure to accurately document and administer controlled medications was confirmed through interviews, record reviews, and medication counts.

An unhandled error has occurred. Reload 🗙