Madera Post Acute Center
Madera Post Acute Center in EL MONTE, CA — inspection on August 21, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
LVN 2 administered Tresiba 55 units to Resident 1.During a telephone interview on 8/20/2025 at 3:37 PM with LVN 2, LVN 2 stated on 8/9/2025 at 5:40 AM, LVN 2 administered Tresiba 55 units to Resident 1.During a concurrent interview and record review on 8/21/2025 at 12:25 PM with the DON, Resident 1's MAR dated 8/1/2025-8/31/2025 was reviewed.
The MAR indicated the 8/9/2025 6:30 AM dose for Tresiba 55-unit[s] subcutaneous injection was not administered.
The DON stated LVN 2 should have documented the 6:30 AM dose of Tresiba administered by LVN 2 on 8/9/2025 in Resident 1's MAR.During a review of the facility's undated Policy and Procedure (P&P) titled, Medication Administration, the P&P indicated, medications will be administered as prescribed by the physician.
The P&P's administration process indicated that the person administering the medication is to initial the resident's medication sheet in the provided space under the appropriate date and time for that particular dose administered.
The P&P's administration process indicated, documentation on the medication sheet is done immediately following administration.
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