Health inspection·December 10, 2025

HSC 1424 (f)(2) (f)(1)A willful material falsification or willful material omission in the health record of a resident of a long-term health care facility is a violation. (2)"Willful material falsification," as used in this section, means any entry in the resident's 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 pressure 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 resident or the care or services provided. 22 CCR § 72523 Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/10/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating a resident (Resident 3) had an unusual occurrence and was sent out to the general acute care hospital (GACH). On 10/22/2025, CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 6 did not willfully falsify Resident 3's medical records indicating the resident was still in the facility when he was hospitalized. 2. Follow its policy and procedure (P&P) titled, "Completion and Correction," which indicated all entries in the medical record were to be accurate. These failures resulted in Resident 3 having inaccurate medical records that did not reflect the actual care provided or his actual clinical condition. Resident 3 was a 79-year-old male, originally admitted to the facility on 7/7/2017, and re-admitted on 4/29/2020 with diagnoses including lack of coordination, abnormalities of gait and mobility, history of falling, hypertension (high blood pressure), and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 10/9/2025, indicated Resident 3's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 3 required set-up or clean-up assistance from staff to bring food or liquid to his mouth, and supervision or touch assistance from staff for personal hygiene. A review of Resident 3's Change of Condition (COC) assessment, dated 10/21/2025, indicated Resident 3 was transferred to the GACH on 10/21/2025 at 10:15 p.m. for vomiting coffee ground emesis (vomit that looks like coffee grounds, a sign of internal bleeding). A review of Resident 3's progress note, written by LVN 6, dated 10/22/2025 at 2:54 p.m., indicated Resident 3's vital signs were stable. The progress note indicated Resident 3 was in no acute distress. The progress note indicated LVN 6 did not observe Resident 3 in pain or experiencing any discomfort. The progress note indicated Resident 3's call light was within reach, and his bed was in the lowest position. During an interview on 10/23/2025 at 2:08 p.m., the Medical Records Director (MRD) stated Resident 3 was transferred to the GACH on 10/21/2025 and was still hospitalized on 10/22/2025. During an interview on 10/23/25 at 2:47 p.m., LVN 6 stated the information documented on 10/22/2025 in Resident 3's progress note was based on information provided to her by another licensed nurse on 10/22/2025. LVN 6 stated she documented a false note on 10/22/2025. LVN 6 stated she did not actually attempt to conduct any of the observations or assessments documented in her note. LVN 6 stated she was assigned to work as a "desk nurse" on 10/22/2025. LVN 6 stated she realized on 10/23/2025 that Resident 3 was not in the facility and decided to strike the note from Resident 3's record. LVN 6 stated it was unacceptable to document false information. LVN 6 stated nursing documentation was to be accurate for the safety of the residents. During an interview on 10/24/2025 at 3:46 p.m., the Assistant Director of Nursing (ADON) stated nursing documentation should be completed in real time if possible. The ADON stated progress notes were deliberately written and entered manually in a narrative format, which required the licensed nurse to consciously think about what was documented into the resident's record. The ADON stated a progress note could not be "accidental" unless intended for another resident and entered in error. The ADON stated LVN 6's progress note was documented falsely. A review of the facility's P&P titled "Completion and Correction," revised 1/2012, indicated documentation was to reflect the medically relevant information concerning the resident. The P&P indicated all entries in the medical record were to be accurate. The facility failed to: 1. Ensure LVN 6 did not willfully falsify Resident 3's medical records indicating the resident was still in the facility when he was hospitalized. 2. Follow its P&P titled, "Completion and Correction," which indicated all entries in the medical record were to be accurate. These failures resulted in Resident 3 having inaccurate medical records that did not reflect the actual care provided or his actual clinical condition. The above facts indicate that there was a willful material falsification in the medical records for the resident.