Health inspection·February 18, 2026

F755  §483.45 Pharmacy Services  §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.  §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who--  §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and  §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

F842  §483.70(h) Medical records.  §483.70(h)(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 1/6/2026 at 9:04 AM, an unannounced visit was made to the facility to investigate a complaint regarding quality of care and a resident death. During the investigation, a review of Resident 1’s medical records was conducted. As a result of the investigation, CDPH determined the facility willfully falsified Resident 1’s Medication Administration Record (MAR) by documenting the following: 1. Indicating that albuterol (bronchodilator medicine that relaxes airway muscles to treat and prevent wheezing, shortness of breath, and chest tightness) was administered on 1/3/2026 at midnight to Resident 1. 2. Indicating that Resident 1 was administered Heparin (an anticoagulant medication that prevents blood from clotting), however the heparin administered belonged to another resident (Resident 3). This deficient practice resulted in an inaccurate depiction of Resident 1’s medication administration record and placed Resident 1, as well as other residents, at risk for serious health complications. A review of Resident 1’s Admission Record indicated Resident 1 was a 80 year old female initially admitted to the facility on 12/21/2023 and readmitted on 1/2/2026, with diagnoses that included obesity due to excess calories, hyperlipidemia (an excess of lipids or fats in the blood), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life).     A review of Resident 1’s History and Physical (H&P) dated 1/2/2026 indicated Resident 1 had the capacity to understand and make decisions.        A review of Resident 1's Order Summary dated 1/2/2026 indicated physician orders to administer Ipratropium Albuterol Inhalation Solution 0.5-2,.5 (3) milligram (mg, unit of measure) per 3 milliliters (ml, unit of measure) 3 ml inhale orally via nebulizer (medical device that turns liquid medicine into a fine mist, allowing it to be inhaled directly into the lungs through a mouthpiece or mask) every 6 hours for respiratory failure, to be given routinely, and Heparin Sodium (Porcine) Injection Solution 5000-unit (unit of measure) per milliliter (ml, unit of measure) inject 500 unit subcutaneously every 8 hours for deep vein thrombosis (DVT, a serious condition where a blood clot forms in a deep vein) prophylaxis, first dose to be taken from cubex.       A review of Resident 1’s Medication Administration Record (MAR) dated 1/2026, the MAR indicated Resident 1 received the following medications:   a. Heparin Injection Solution 5000 unit was last given on 1/2/2026 at 10 PM. b. Albuterol Inhalation Solution was last given on 1/3/2026 at 12 AM.     A review of the facility’s Cubex receipts titled “Transactions by Cabinet C6” and “Controlled Subs, by Cab (cabinet), and bin, by time C81” dated 1/2/2026 to 1/3/2026 indicated no transactions were made for Resident 1.         A review of the Pharmacy Delivery Receipt dated 1/3/2026, the receipt indicated a delivery for Resident 1’s medications on 1/3/2026 at 5:15 AM. The receipt indicated the following medications were delivered and returned to pharmacy:  a. Solifenacin (medication used to treat overactive bladder symptoms like urinary urgency, frequency, and incontinence) 5 mg tablet, Quantity: 14, 1 Package . b. Sertraline Hydrochloride (used to treat depression [mood disorder that causes persistent feeling of sadness and loss of interest]) 25 mg tablet, Quantity: 14, 1 Package. c. Isosorbide Mononitrate (medication used to prevent chest pain from coronary heart disease) 20 mg tablet, Quantity: 14, 1 Package. d. Isosorbide Mononitrate 10 mg tablet, Quantity: 14, 1 Package e. Ondansetron Hydrochloride (medication to prevent nausea and vomiting) 4 mg tablet, Quantity: 30, 1 Package. f. Metoprolol Succinate Extended Release (ER) (used to treat chest pain [angina] and hypertension [high blood pressure]) 25 mg tablet, Quantity: 14, 1 Package  g. Ipratropium Albuterol Inhalation Solution 0.5-3(2.5) mg/ 3 ml, Quantity: 90, 1 Package h. Heparin Sodium 5000 unit/ml vial, Quantity: 21, 1 Package i. Gabapentin (medication used to help control partial seizures [convulsions] in the treatment of epilepsy [brain condition that causes recurring seizures]) 100 mg capsule, Quantity: 84, 1 Package j. Clopidogrel (antiplatelet medication that prevents blood platelets from sticking together, reducing the formation of dangerous clots that can cause heart attacks and strokes) 75 mg tablet, Quantity: 14, 1 Package k. Atorvastatin (medication that treats high cholesterol [waxy, fat-like substance throughout the body) 20 mg tablet, Quantity: 14, 1 Package            During a telephone interview on 1/8/2026 at 10:49 AM, licensed vocational nurse (LVN) 2 stated and confirmed she administered Heparin to Resident 1 during her 3 PM to 11 pm shift on 1/2/2026. LVN 2 stated going to the cubex to take out the Heparin but could not obtain it since “it took too much time,” because the cubex “takes time to process with the pharmacy.” LVN 2 stated the processing time for the pharmacy to verify on the cubex to obtain the medication was about “15 minutes.”  LVN 2 stated she then used a vial of Heparin that belonged to another resident, Resident 3, who was receiving the same dose as Resident 1. LVN 2 stated she did not document that the dose of heparin administered to Resident 1 belonged to Resident 3.    During an interview with the Director of Nursing (DON) at 1/8/2026 at 11:59 AM, the DON stated licensed nurses should never borrow medications from another resident. The DON stated when the cubex is used to take out medication, the licensed nurse would call the pharmacy, wait 5-10 minutes to remove the medication from the cubex. The DON stated LVN 2 should not have used medication that belonged to another resident, and she should have called the pharmacy and waited to get medication from the cubex.        During a telephone interview on 1/8/2026 at 2:01 PM, LVN 1 stated he did not administer Albuterol to Resident 1. LVN 1 stated he does not remember administering Albuterol or any other medications to Resident 1 and was unable to explain as to why he/she clicked yes indicating administering the medication in the MAR.    A review of the facility’s policy and procedure (P&P) titled “Six Rights of Medication Administration” dated 5/2018 indicated the six rights of medication administration are followed in order to ensure safety and accuracy of administration. The P&P indicated the six rights of medication are as follows: a. Right Resident- Resident is identified prior to medication administration. b. Right Time- Medications are administered within prescribed time frames.  c. Right Medication order- Medications are checked against the order before they are given. d. Right Dose - Medications are administered according to the dose prescribed. e. Right Route - Medications are administered according to the route prescribed. f. Right Documentation - Document administration or refusal of the medication after the administration or attempt and note any concerns  the facility willfully falsified Resident 1’s Medication Administration Record (MAR) by documenting the following: 1. Indicating that albuterol (bronchodilator medicine that relaxes airway muscles to treat and prevent wheezing, shortness of breath, and chest tightness) was administered on 1/3/2026 at midnight to Resident 1. 2. Indicating that Resident 1 was administered Heparin (an anticoagulant medication that prevents blood from clotting), however the heparin administered belonged to another resident (Resident 3). This deficient practice resulted in an inaccurate depiction of Resident 1’s medication administration record and placed Resident 1, as well as other residents, at risk for serious health complications. The above facts indicate that there was a willful material falsification in Resident 1’s medical record.