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F0755
E

Failure to Administer Medications as Ordered, Resulting in Late Doses

Willits, California Survey Completed on 12-29-2025

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 administer medications as ordered by the prescriber for two of three sampled residents, resulting in late medication administration on two separate days. For one resident with diagnoses including trigeminal neuralgia and syndrome of inappropriate secretion of antidiuretic hormone, five scheduled medications were administered more than an hour past the prescribed 4 p.m. time on two consecutive days. The Director of Nursing (DON) confirmed that these medications, which included gabapentin, Keppra, Flomax, duloxetine, and lamotrigine, were given late, outside the facility's policy requiring administration within 60 minutes of the scheduled time. Another resident, admitted with bilateral osteoarthritis of the hip, benign prostatic hyperplasia, and atherosclerotic heart disease, also received three scheduled medications late on two consecutive days. The medications, including diclofenac gel, atorvastatin, and tamsulosin, were scheduled for 8 p.m. but were administered more than an hour late. The DON acknowledged that these medications should have been given within the required time frame and confirmed the late administration. Facility policy specifies that medications must be administered as prescribed and within 60 minutes of the scheduled time.

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