Health inspection·March 19, 2026

§483.70(i) Medical records. §483.70(i)(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 1424(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. §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 2/11/2026 the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 2) received medications that made him confused and was prescribed a medication for depression, but he was not depressed. The complaint alleged the facility gave residents’ medication to keep them sleep during the day because many residents’ were found sleeping during the day. On 2/11/2026, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. During the investigation, the CDPH determined allegations related to Resident 2 could not be substantiated, however the CDPH found Resident 4’s medications were left unattended on his bedside table and were not administered to him. The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 1 accurately documented the medication administration for Resident 4. 2. Follow its Policy and Procedure (P/P), titled, “Medication Administration” dated 9/2010 that indicated “the individual that administers the medication dose records the administration on the resident’s MAR directly after the medication is given. “Pour- Pass -Chart” is the acceptable method for medication preparation, administration and documentation.” Theses deficient practices resulted in Resident 4 not receiving medications prescribed to him, but his clinical records indicated he was administered medications he did not receive. This deficient practice had the potential to negatively impact on Resident 4’s health by mismanagement of his medication regimen and non-continuity of care. Resident 4, an 83 year-old male, was initially admitted to the facility on 6/6/2022 and readmitted on 6/17/2025. Resident 4 had diagnoses including essential primary hypertension ([HTN] high blood pressure), unspecified atrial fibrillation ([a-Fib] irregular heart rhythm), anemia (low red blood cell count), congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).   A review of Resident 4’s Minimum Data Set ([MDS] a resident assessment tool) dated 6/27/2025, indicated Resident 4’s cognition was severely impaired, and he required supervision with toilet hygiene, showering/bathing.   A review of Resident 4’s Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 2/2026, indicated the following medications were administered to Resident 4 on 2/11/2026 at 9 a.m.:   1. Chlorthalidone oral tablet 50 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) give ½ tablet daily for CHF.   2. Ferrous Sulfate (Iron) 325 mg give one tablet daily as a supplement.   3. Memantine HCL 5 mg give one tablet daily for Alzheimer’s disease, unspecified.   4. Multi-Vitamin one tablet daily as a supplement.   5. Docusate Sodium 100 mg give one capsule two times daily for bowel management.     6. Hydrochlorothiazide 50 mg give one tablet daily for edema (swelling).     During an observation on 2/11/2026 at 9:45 a.m., LVN 1 entered Resident 4’s room with a medication cup then left the room without the medication cup. At 10 a.m., and a subsequent observation at 11:29 a.m., a medication cup with six pills in it was observed sitting on Resident 4’s bedside table.     During an interview and concurrent review of Resident 4’s MAR dated 2/2026 on 2/11/2026 at 12:21 p.m., Resident 4’s MAR indicated Chlorthalidone 50 mg, Ferrous Sulfate 325 mg, Memantine HCL 5 mg, Docusate Sodium 100 mg, and hydrochlorothiazide 50 mg were documented as administered to Resident 4 at 9:55 a.m. LVN 1 stated she placed the medication cup with pills in it on Resident 4’s bedside table and left the room, because she was called to help another resident. LVN 1 stated it was not her usual practice to leave medications unattended at a resident’s bedside because another resident could ingest them, but she became busy. LVN 1 acknowledged she signed Resident’s 4 MAR indicating Resident 4 was administered medication that he was not given and stated she should not have signed Resident 4’s MAR to indicate that. During an interview on 2/12/2026 at 4:15 p.m., the Director of Nursing (DON) stated the correct way to pass medications was to pour the medication, pass the medication and sign the MAR. Signing the MAR before the medications were administered was considered false documentation.   A review of the facility’s P&P titled, “Medication Administration” dated 9/2010, indicated “for residents not in their room or otherwise unavailable to receive medication on the pass, the MAR is flagged (e.g., tags colored plastic strips or paper clip). After completing the medication pass, the nurse returns to the missed resident to administer the medication. The individual that administers the medication dose records the administration on the resident’s MAR directly after the medication is given. “Pour- Pass -Chart” is the acceptable method for medication preparation, administration and documentation.” The facility failed to: 1. Ensure LVN 1 accurately documented the medication administration for Resident 4. 2. Follow its P/P, titled, “Medication Administration” dated 9/2010 that indicated “the individual that administers the medication dose records the administration on the resident’s MAR directly after the medication is given. “Pour- Pass -Chart” is the acceptable method for medication preparation, administration and documentation.” These deficient practice resulted in Resident 4 not receiving medications prescribed to him, but his clinical records indicated he was administered medications he did not receive. This deficient practice had the potential to negatively impact on Resident 4’s health by mismanagement of his medication regimen and non-continuity of care. The above facts indicates there was a willful material falsification in the medical record of Resident 4.