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F0755
D

Failure to Provide Scheduled Medications and Document Physician Consultation

San Dimas, California Survey Completed on 12-11-2025

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 provide scheduled medications to a resident who was admitted with multiple diagnoses, including a femur fracture, hip dislocation, and neuropathy. Upon admission, the resident had physician orders for bupropion SR and gabapentin, both of which were due to be administered at 9:00 PM on the day of admission. However, the medications were not given as scheduled because the pharmacy did not process the order until the following day. There was no documentation in the resident's medical record indicating that the attending physician was consulted about delaying the initiation of these medications. The resident was moderately impaired in cognitive skills and dependent on staff for personal care, as documented in the Minimum Data Set. The facility's policy required staff to consult with the prescriber and document any changes if a medication could not be started as ordered, but this was not done. The failure to provide the scheduled medications and to document physician consultation constituted a deficiency in meeting the pharmaceutical needs of the resident.

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