Meadow Creek Post-Acute: Medication Timing Failure - CA
The patient, identified in inspection records only as Resident 1, had been prescribed Epclusa, a medication used to treat chronic Hepatitis C, along with Theophylline, an extended-release drug for lung disease, Baclofen, a muscle relaxant, and Losartan Potassium for high blood pressure. All four were ordered for 9 a.m. All four were given at 10:32 a.m., one hour and 32 minutes late.
No physician was notified. No late-medication order was obtained.
Resident 1 was cognitively intact, according to a resident assessment completed May 10. The patient had been admitted to the facility with spinal cord compression, a cervical disc disorder affecting the neck with associated spinal cord injury, and hypertension. The inspection report does not say why the medications were late.
A federal complaint inspection on May 26 caught the delay through a review of the facility's Medication Administration Audit Report. The record showed the time plainly: 10:32 a.m., for drugs prescribed at 9.
When inspectors interviewed the nurse who administered the medications, Licensed Vocational Nurse 2 is not quoted directly in the report. But LVN 1, interviewed the same morning at 10:25 a.m., laid out what the standard was supposed to be: medications are to be given within one hour before or one hour after their scheduled time. If a medication cannot be given on time, the physician must be notified for a late administration order.
LVN 2 missed both requirements. The medications were given outside the one-hour window, and no call was made.
The Director of Nursing confirmed what the records showed. In an interview at 10:47 a.m. on May 26, while reviewing the audit report alongside inspectors, the DON acknowledged that LVN 2 had administered the 9 a.m. medications late. The DON explained why the physician call matters: a late dose can result in either a subtherapeutic effect, meaning the medication fails to do what it's supposed to do, or a toxic dose, meaning the next scheduled administration arrives before the body has processed the delayed one.
For Resident 1, the practical stakes of that calculus varied by drug. Epclusa, a once-daily antiviral, works against Hepatitis C through consistent daily dosing. Theophylline, particularly in its extended-release form, is a narrow therapeutic window drug, meaning the difference between a dose that works and one that causes adverse effects is not large. Baclofen, as a muscle relaxant for a patient with spinal cord compression, addresses the kind of pain and spasticity that does not wait for administrative delays. Losartan, for blood pressure, is also a once-daily medication where timing consistency supports stable control.
The inspection classified the harm level as minimal harm or potential for actual harm. No evidence in the report indicates Resident 1 suffered a measurable medical consequence from the delay. But the DON's own words described the risk clearly: a subtherapeutic effect, or a toxic dose.
The facility's own written policy, in place since April 2019, states that medications are to be administered within one hour of their prescribed time. The policy existed. The nurses knew it. The one-hour window passed anyway.
Inspectors found the violation affected a few residents out of three sampled, with Resident 1 as the sole identified case. The report does not indicate how often late administrations occur at the facility, or whether LVN 2 had prior documentation of similar delays.
What the record does show is a patient with Hepatitis C, a lung condition, spinal cord damage, and high blood pressure, lying in a post-acute facility on a Saturday morning in May, waiting for medications that should have arrived at 9 o'clock. They arrived at 10:32. Nobody called the doctor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadow Creek Post-acute from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 21, 2026 · Our methodology
MEADOW CREEK POST-ACUTE in PARAMOUNT, CA was cited for violations during a health inspection on May 26, 2026.
All four were ordered for 9 a.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.