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F0761
D

Unattended Medications Left in Resident Room

Saratoga, California Survey Completed on 11-25-2025

Penalty

Fine: $49,680
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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

Medications, including Zyflamend herbal pain relief, Apixaban, cod liver oil, fish oil, and progesterone, were found left unattended in a resident's room inside medication cups on a tray table next to the resident's bed. The resident, who had diagnoses of atrial fibrillation, anemia, and immunodeficiency, and a severely impaired cognition score (BIMS 5/15), was in bed at the time of observation, with no licensed staff present. The medications had been prepared and left in the room by an LVN, who confirmed that the medications were ordered by a physician and stated that the resident would take them when her son visited. Interviews with the LVN, DON, and consultant pharmacist confirmed that medications should not be left unattended in a resident's room and should be stored in locked compartments until administration. Facility policy also requires that drugs and biologicals be stored in locked compartments and only accessible to authorized personnel. The failure to secure medications as required was observed and acknowledged by staff.

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