Other·April 24, 2026

California Health and Safety Code §1424(f) (1) Any willful material falsification or willful material omission in the health record of a patient of a long-term health care facility is a violation. (2) “Willful material falsification,” as used in this section, means any entry in the patient health care record pertaining to the administration of medication, or treatments ordered for the patient, or pertaining to services for the prevention or treatment of decubitus ulcers or contractures, or pertaining to tests and measurements of vital signs, or notations of input and output of fluids, that was made with the knowledge that the records falsely reflect the condition of the Patient, or the care or services provided. F842 Title 42 Code of Federal Regulations §483.70(h) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized On 3/9/2026, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual health recertification survey. During the visit, CDPH determined that records were falsified and inaccurate. The facility: 1. Willfully made materially false entries on the Medication Administration Record (MAR - a record of all active physician orders and medications administered to a resident) of Resident 33 pertaining to the administration of the medication Trelegy (a brand name combination medication used to treat chronic obstructive pulmonary disease [COPD – a disease causing shortness of breath and chest congestion {feeling of tightness, fullness or heaviness in the chest} due to mucus buildup in the lungs or airways]), as evidenced by: 1. LVN 4’s false entries documenting daily administration of Trelegy, between August 1, 2025 and March 9, 2026. 2. LVN 4’s statement that all entries of Trelegy doses recorded in Resident 33’s MAR initialed from August 1, 2025 to March 9, 2026 had been made with the knowledge that the records falsely reflect the care or services provided, as the facility did not have any Trelegy because the pharmacy had never delivered any supply after July 2025, and nursing staff had failed to reorder it or notify the physician, pharmacy, or Director of Nursing of the missing medication. 3. Additional LVNs (LVN 5, LVN 7, LVN 13, and LVN 14) acknowledging initialing the MAR to show Trelegy was administered when they had knowledge that the Trelegy had not been administered. 2. Relied on the falsified MAR entries as evidence that Trelegy had been administered, as evidenced by multiple LVNs’ statements that a checkmark and initials on the MAR indicate a dose was given, and that if a medication is unavailable, it should not have a checkmark on the MAR. Because staff treat the presence of a checkmark as confirmation of administration, the false entries created the appearance that Resident 33 was receiving the daily COPD inhaler as ordered. As a result of these actions, the medical record of Resident 33 contained willful material falsification. The falsified entries obscured the fact that a physicianordered COPD inhaler was not administered for more than seven months, creating a clinical record that did not accurately represent the resident’s treatment history or condition. In addition, these falsified entries were relied upon by licensed clinical staff during ongoing care and had the potential to detrimentally affect medication administration, treatment decisions, and care planning. A review of Resident 33’s Admission Record (a document containing demographic and diagnostic information), dated 3/9/2026, indicated Resident 33 was originally admitted to the facility on 8/22/2018 and re-admitted on 1/30/2025 with diagnoses including COPD. A review of Resident 33’s Minimum Data Set (MDS – a resident assessment tool), dated 2/4/2026, indicated Resident 26 was cognitively (mental action or process of acquiring knowledge and understanding) intact and able to understand others. A review of Resident 33’s Order Summary Report (a report listing physicians’ orders for the resident), dated 3/8/2026, indicated Resident 33 was prescribed Trelegy to inhale one (1) puff orally (by mouth) once a day for congestion, starting 7/16/2025. A review of Resident 33’s MAR, for March 2026, indicated Resident 33 was prescribed Trelegy 1 puff oral inhalation (delivery of a medication into the respiratory tract through breathing, typically through the mouth or nose, so the medication is absorbed through the lungs) once a day for congestion, to be administered at 9 a.m. A review of Resident 33’s MARs, dated between 8/1/2025 and 3/9/2026, indicated Trelegy was documented as administered daily at 9 a.m. by several licensed vocational nurses. During an observation on 3/9/2026 at 9:10 a.m., at Medication Cart Station 2, Licensed Vocational Nurse 4 (LVN 4) was observed administering dorzolamide with timolol (a combination medication used for glaucoma [a group of eye diseases that damage the optic nerve—the cable connecting the eye to the brain—often due to high fluid pressure inside the eye]) drops in the eye, omega-3 (a supplement) tablet, Saccharomyces boulardii (a supplement) capsule, vitamin d3 (a supplement) tablet, gabapentin (a medication used for neuropathy [nerve damage]) tablet, and polyethylene glycol (a medication used for constipation) liquid orally to Resident 33. LVN 4 did not administer Trelegy oral inhalation. During an interview on 3/9/2026 at 12:35 p.m. with LVN 4, LVN 4 stated LVN 4 administered dorzolamide with timolol, omega-3, Saccharomyces boulardii, vitamin d3, and gabapentin to Resident 33, and did not administer Trelegy oral inhalation that day (3/9/2026) at 9:10 a.m. to Resident 33, as prescribed by Resident 33’s physician. LVN 4 stated Trelegy oral inhalation was not available in Medication Cart 2 or in the facility. LVN 4 stated that Trelegy is a medication used for COPD and not administering and/or missing a dose could harm Resident 33 by causing breathing difficulty leading to potential hospitalization. LVN 4 stated that LVN 4 documented in the MAR that Trelegy was administered to Resident 33 at 9 a.m. that day (3/9/2026) knowing that Trelegy was not administered. During a concurrent interview and record review on 3/9/2026 at 3:10 p.m. with LVN 4, Resident 33’s MARs, from 8/1/2025 through 3/9/2026 were reviewed. LVN 4 stated Resident 33's Trelegy inhaler was never received from the pharmacy and that LVN 4 was unaware of the reason for non-delivery. LVN 4 further stated that the checkmarks on the MAR with her (LVN 4) initials from 8/1/2025 through 3/9/2026 indicated that Trelegy was successfully administered to Resident 33. LVN 4 stated LVN 4 knowingly documented Trelegy as administered 33 times at 9 a.m. on the following dates: 9/28/2025, 10/5/2025, 10/11/2025, 12/5/2025, 12/17/2025, 12/18/2025, 12/22/2025, 12/24/2025, 12/25/2025, 12/30/2025, 1/4/2026, 1/8/2026, 1/10/2026, 1/11/2026, 1/17/2026, 1/26/2026, 1/27/2026, 1/28/2026, 2/4/2026, 2/15/2026, 2/18/2026, 2/20/2026, 2/22/2026, 2/23/2026, 2/26/2026, 2/27/2026, 2/28/2026, 3/3/2026, 3/4/2026, 3/5/2026, 3/6/2026, 3/8/2026, and 3/9/2026. LVN 4 stated that when a medication is unavailable, it should not be documented as administered on the MAR. LVN 4 further stated that if a medication administration is not completed, the MAR should reflect that the medication was not given. LVN 4 stated that documenting Trelegy as administered when it was not given resulted in an inaccurate clinical record for Resident 33. During an interview on 3/9/2026 at 3:15 p.m., with the Director of Nursing (DON), the DON stated that the pharmacy had not delivered Resident 33’s Trelegy and that the facility had not received Resident 33’s Trelegy since 7/16/2025. The DON stated that as a result, Resident 33 did not have an available supply of Trelegy following completion of a 14-day supply on 7/31/2025. The DON further stated that when a medication is unavailable to administer, the LVNs are required to notify the pharmacy, the resident’s physician, and to inform the DON about the missing medication as it will be treated as a medication error. The DON stated none of the LVNs contacted her about missing medications for Resident 33. The DON stated that it was unacceptable for staff to sign the MARs indicating administration of Trelegy between 8/1/2025 and 3/9/2026 when the medication was not available in the facility. The DON further stated that not administering Trelegy as prescribed could result in worsening congestion, exacerbation of COPD, and potential hospitalization. During an interview on 3/9/2026 at 3:39 p.m., with Resident 33, Resident 33 stated that Resident 33 received an inhaler (Resident 33 was unable to recall the medication name) for her (Resident 33) bronchitis (inflammation of the tubes in the lungs that cause mucus and cough) last summer (between June to August of 2025, Resident 33 was unable to recall exact dates) and had not received it since that time. During a concurrent interview and record review on 3/10/2026 at 10:52 a.m., with LVN 5, Resident 33’s MARs, between September 2025 and November 2025, were reviewed. LVN 5 stated that the checkmarks and her (LVN 5) initials on the MAR between 9/1/2025 and 11/2/2025 indicated that Trelegy had been administered to Resident 33. LVN 5 further stated Resident 33's Trelegy inhaler was not available in the facility and that LVN 5 did not follow up with the pharmacy regarding the refill status. LVN 5 stated that when a medication is unavailable, it should not have a checkmark on the MAR and it should not be documented as administered on the MAR. LVN 5 stated LVN 5 knowingly documented Trelegy as administered 21 times at 9 a.m. on 9/17/2025, 9/22/2025, 9/23/2025, 9/24/2025, 9/29/2025, 9/30/2025, 10/1/2025, 10/6/2025, 10/7/2025, 10/13/2025, 10/15/2025, 10/18/2025, 10/19/2025, 10/20/2025, 10/24/2025, 10/25/2025, 10/26/2025, 10/27/2025, 10/30/2025, 10/31/2025, and 11/2/2025. LVN 5 stated that documenting Trelegy as administered when it was not given resulted in an inaccurate clinical record for Resident 33. During a concurrent interview and record review on 3/10/2026 at 11:06 a.m., with LVN 7, Resident 33’s MARs between November 2025 and February 2026 were reviewed. LVN 7 stated that the checkmarks and her (LVN 7) initials on the MAR between 11/22/2025 and 2/25/2026 indicated that Trelegy had been administered to Resident 33. LVN 7 further stated Resident 33's Trelegy inhaler was not available in the facility and that LVN 7 failed to re-order from pharmacy on several occasions. LVN 7 stated that when a medication is unavailable, it should not have a checkmark on the MAR. LVN 7 stated LVN 7 knowingly documented Trelegy as administered five (5) times at 9 a.m. on 11/22/2025, 1/21/2026, 1/22/2026, 2/16/2026, and 2/25/2026. During a concurrent interview and record review on 3/10/2026 at 11:26 a.m. with LVN 13, Resident 33’s MARs, between August 2025 and February 2026, were reviewed. LVN 13 stated the checkmarks on the MAR with her (LVN 13) initials between 8/5/2025 and 2/24/2026 indicated that Trelegy was successfully administered to Resident 33. LVN 13 stated Resident 33's Trelegy inhaler was not available in the facility and that LVN 13 failed to inform the DON, Assistant Director of Nursing (ADON), Registered Nurse (RN) supervisors, and the physician and failed to re-order the medication from pharmacy. LVN 13 stated if a medication was unavailable, it should not have a checkmark on the MAR. LVN 13 stated LVN 13 marked the MAR possibly in error that Trelegy was administered 11 times at 9 a.m. on 8/5/2025, 8/18/2025, 11/5/2025, 11/12/2025, 11/17/2025, 11/24/2025, 2/3/2026, 2/6/2026, 2/12/2026, 2/17/2026, and 2/24/2026. During a concurrent interview and record review on 3/10/2026 at 11:40 a.m., with LVN 14, Resident 33’s MARs, between November 2025 and January 2026 were reviewed. LVN 14 stated that the checkmarks and her (LVN 14) initials on the MAR between 11/18/2025 and 1/7/2026 indicated that Trelegy had been administered to Resident 33 5 times at 9 a.m. on 11/18/2025, 11/20/2025, 12/25/2025, 1/5/2026, and 1/7/2026. LVN 14 stated Resident 33's Trelegy inhaler was not available in the facility and LVN 14 stated that when a medication is unavailable, it should not have a checkmark on the MAR and it should not be documented as administered on the MAR. LVN 14 stated due to high workload LVN 14 likely documented administration in error by completing the MAR at the end of the medication pass without verifying which medications were actually administered and which were not. LVN 14 stated that, as a result, LVN 14 failed to accurately identify medications requiring reordering or follow-up with the pharmacy. A review of the facility’s Policy and Procedures (P&P) titled, “Medication Administration-General Guidelines,” last reviewed on 2/20/2026, indicated “Medications are administered as prescribed in accordance with good nursing principles and practices… 1. The individual who administers the mediation dose records the administration on the resident’s MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented… 4. The resident’s MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration.” A review of the facility’s P&P titled, “Administering Medications,” last reviewed on 2/20/2026, indicated: “20. The individual administering the medication initials on the resident’s MAR on the appropriate line after giving each medication and before administering the next dose. 21. As required or indicated for a medication, the individual administering the medication records in the resident’s medical record: a. date and time the medication was administered.” The facility: 1. Willfully made materially false entries on the MAR of Resident 33 pertaining to the administration of the medication Trelegy, as evidenced by: 1. LVN 4’s false entries documenting daily administration of Trelegy, between August 1, 2025 and March 9, 2026. 2. LVN 4’s statement that all entries of Trelegy doses recorded in Resident 33’s MAR initialed from August 1, 2025 to March 9, 2026 had been made with the knowledge that the records falsely reflect the care or services provided, as the facility did not have any Trelegy because the pharmacy had never delivered any supply after July 2025, and nursing staff had failed to reorder it or notify the physician, pharmacy, or Director of Nursing of the missing medication. 3. Additional LVNs acknowledging initialing the MAR to show Trelegy was administered when they had knowledge that the Trelegy had not been administered. 2. Relied on the falsified MAR entries as evidence that Trelegy had been administered, as evidenced by multiple LVNs’ statements that a checkmark and initials on the MAR indicate a dose was given, and that if a medication is unavailable, it should not have a checkmark on the MAR. Because staff treat the presence of a checkmark as confirmation of administration, the false entries created the appearance that Resident 33 was receiving the daily COPD inhaler as ordered. As a result of these actions, the medical record of Resident 33 contained willful material falsification. The falsified entries obscured the fact that a physicianordered COPD inhaler was not administered for more than seven months, creating a clinical record that did not accurately represent the resident’s treatment history or condition. In addition, these falsified entries were relied upon by licensed clinical staff during ongoing care and had the potential to detrimentally affect medication administration, treatment decisions, and care planning. The above facts indicate that there was a willful material falsification in the medical records for Resident 33.