The August 2025 inspection, triggered by a complaint, identified 14 separate deficiencies at the facility.
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The finding came during a complaint inspection at Immanuel Skilled Care Center, completed August 20, 2025.
That was the explanation a Licensed Practical Nurse gave to inspectors during a complaint investigation completed August 20, 2025.
Inspectors found Meridian Center was not meeting that deadline.
Inspectors classified the violation as a pattern, meaning this was not an isolated lapse.
What remained in the kitchen was a single set of printed slips from whenever that manager walked out.
The nurse, identified in inspection records as LVN 2, administered Tresiba to Resident 1 at 5:40 AM on August 9, 2025, at Madera Post Acute Center.
It had started, according to a nurse interviewed during the investigation, roughly the size of a dime.
The admission came on August 12, 2025, when inspectors sat down with the administrator.
The inspection, triggered by a complaint, was completed August 20, 2025.
The citation, issued August 21, falls under a category that covers pharmacy service failures.
A pattern means inspectors didn't find an isolated slip.