F0755

E

Untimely Medication Administration for Multiple Residents

South Gate, California Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer medications as ordered by physicians and within the facility’s own one-hour before/after administration window for five sampled residents. The facility’s policy on medication administration, dated July 2013, states that drugs must be administered in accordance with written physician orders and within one hour before or after the scheduled administration time. Interviews with nursing staff and the ADON confirmed their understanding that medications must be given on time, within a one-hour window, and that certain medications, such as diabetic, blood pressure, and seizure medications, have specific timing and food-related requirements.

For one resident with type 2 DM and HTN admitted in February 2026, the MAR showed metformin 1000 mg scheduled for 7:30 a.m. On the survey date at 9:55 a.m., an LVN stated she was going to administer the metformin and acknowledged it was late. At 10:00 a.m., the LVN handed the metformin to the resident, who refused it, stating that his PCP instructed him to take metformin with the last bite of breakfast and not two hours later. Another resident with type 2 DM and HTN had clonidine 0.1 mg scheduled for 9:00 a.m.; at 10:18 a.m., an LVN reported he was preparing this medication and acknowledged it was scheduled for 9:00 a.m. but that he was running behind on passing medications.

A resident with CHF and atrial flutter had glipizide 2.5 mg scheduled for 7:30 a.m., yet an LVN was observed administering this medication at 10:40 a.m. Another resident with HTN and CHF had carvedilol 25 mg scheduled for 7:30 a.m. and furosemide 20 mg scheduled for 9:00 a.m.; at 10:28 a.m., an LVN stated he was preparing and going to administer both medications at that time. A further resident with end stage renal disease and hydrocephalus had levetiracetam 500 mg and valproic acid 250 mg both scheduled for 9:00 a.m.; at 10:45 a.m., an LVN stated he was preparing and going to administer these medications then. Staff interviews documented that late administration of pain, diabetic, blood pressure, and seizure medications can affect pain control, blood sugar control, blood pressure control, and seizure risk, and that medications must be given on time, especially those given multiple times per day, to avoid doses being too close together.