Health inspection·March 26, 2026

Regulatory Violations  Willful Material Falsification CLASS WMF CITATION -- PATIENT RECORD California Health & 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 resident or the care or services provided. (3) "Willful material omission," as used in this section, means the willful failure to record any untoward event that has affected the health, safety, or security of the specific patient, and that was omitted with the knowledge that the records falsely reflect the condition of the resident or the care or services provided. 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 2/02/2026 at 8:32 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility during a Health Recertification Survey. During the Health Recertification Survey, CDPH determined that the facility willfully falsified Resident 1, 2, and 3’s medical records as described below:  1. Licensed Vocational Nurse (LVN) 2 willfully falsified Resident 1’s physician order dated 2/5/2026 by documenting a physician order that had not been confirmed with Resident 1’s attending physician (MD 1). LVN 2 recorded an order from MD 1 indicating approval to extend Resident 1’s morning medication pass by two hours on 2/5/2026, despite not notifying MD?1 of any anticipated delay or receiving authorization for the extension. Interviews revealed that LVN?2 had spoken with MD?2 regarding a possible extension for another resident (Resident?2), yet LVN 2 still entered MD?1 as the ordering physician in Resident?1’s clinical record. LVN?2 further admitted entering the physician order two hours (10:45 AM instead of 8:45 AM) after the time of the actual call. Additionally, the orders she entered did not include the specific timeframe for the extension (from 9:00?AM to 11:00?AM), resulting in incomplete and misleading documentation. 2. LVN 2 willfully falsified Resident 2’s physician order dated 2/5/2026 by documenting a physician order that had not been confirmed with Resident 2’s attending physician (MD 2). LVN 2 recorded an order from MD 2 indicating approval to extend Resident 2’s morning medication pass by two hours on 2/5/2026. During the validation interview, MD 2 reported that LVN 2 was instructed to call back on 2/5/2026 to provide the resident’s name and the specific morning medications that would be delayed. LVN 2 did not return the call to provide the requested clarification. LVN?2 admitted that she had intended to provide the missing details later but never did so. Despite failing to get required name and medication information, necessary information for MD 2’s order. LVN 2 documented that an order was received from MD 2 to extend the morning medication pass for Resident 2 by two hours on 2/5/2026. LVN?2 further admitted entering the physician order two hours (10:43 AM instead of 8:45 AM) after the time of the actual call. Additionally, the orders she entered did not include the specific timeframe for the extension (from 9:00?AM to 11:00?AM), resulting in incomplete and misleading documentation. 3. RN 3 willfully falsified Resident 3’s psychotropic medication informed consent for Imipramine (antidepressant) by documenting a handwritten note stating that DON 2 had validated that Psychiatric-Mental Health Nurse Practitioner (PMHNP 1) obtained the informed consent from Family [FM] 3) on 1/06/2026 prior to administering the Imipramine psychotropic medication. During validation interviews, DON 2 reported that she did not validate Resident 3’s Imipramine informed consent with PMHNP 1 on 1/06/2026 and did not write the handwritten informed consent dated 1/06/2026 for Imipramine in Resident 3’s medical record. 4. RN 3 willfully falsified Resident 3’s psychotropic medication informed consent for Trazodone (antidepressant) by documenting a handwritten note stating that LVN 3 had validated that PMHNP 1 obtained informed consent from Resident 3’s responsible party (Family [FM] 3) on 1/15/2026 prior to administering the Trazodone. During validation interviews, LVN 3 reported that she did not validate Resident 3’s Trazodone informed consent with PMHNP 1 on 1/15/2026 and did not write the handwritten informed consent dated 1/15/2026 for Trazodone found in Resident 3’s medical record. The facility’s failures to accurately document and maintain truthful clinical records falsely reflect the services provided and constitute willful material falsification and willful material omissions. These actions resulted in Residents 1, 2, and 3’s clinical records falsely reflect the residents’ condition or the care and services provided and compromise resident safety. 1. A review of Resident 1’s Admission Record (AC), the AC indicated Resident 1 was a 50-year-old male admitted to the facility on 1/30/2026 with diagnoses that included Type 2 Diabetes Mellitus with foot ulcer, essential hypertension, and hyperlipidemia. The AC indicated Resident 1 was responsible. The AC indicated that Resident 1’s primary attending physician is MD 1 and another provider that works under MD 1 is Nurse Practitioner (NP) 1. A review of Resident 1’s History and Physical (H&P) signed and dated by Nurse Practitioner (NP) 1 on 1/30/2026, the H&P indicated the resident had the capacity to understand and make decisions.   A review of Resident 1’s electronic physician order dated 2/5/2026 at 10:45 AM, authored by LVN 2, the order indicated a telephone order from MD 1 (Resident 1’s attending physician) indicating: “May extend AM med [medication] pass up to 2 hours.” The documented physician order lacked specific details, including which specific morning medications were to be extended and the exact timeframe for the extension (start and end times). A review of Resident 1’s electronic Medication Administration Record (MAR) on 2/5/2026 timed at 11:43 AM, Resident 1’s scheduled 9 AM medications were reviewed. During this review, Resident 1’s scheduled 9 AM medications were still not documented as given by a licensed nurse, almost three [3] hours from the scheduled time of administration. The AM medications scheduled at 9 AM were Alogliptin 12.5 mg tablet once daily, Norvasc 5 mg oral tablet once daily, Cholecalciferol 1000 units tablet, 2 tablets once daily, Docusate sodium 100 mg tablet once daily, Famotidine 20 mg oral tablet once daily, Gabapentin 300 mg capsule twice daily, and Vitamin B12 tablet 2 tablets once daily. On 2/05/2026 at 4:00 PM, during an attempt to interview Resident 1’s attending physician (MD 1), the call was transferred by MD 1’s office to the on-call covering physician, MD 3. During the telephone interview, MD 3 stated that he was covering for MD 1, who was on vacation the entire week (2/2/26 to 2/6/26). MD 3 further stated that he did not receive any call from the facility or LVN 2 regarding a delay in Resident 1’s morning medications on 2/05/2026. MD 3 suggested that LVN 2 may have contacted Nurse Practitioner (NP) 1, who also works under MD 1. During a telephone interview on 2/05/2026 at 4:46 PM, NP 1 stated that he did not receive any phone call from facility staff or a licensed nurse on that date requesting an order to extend medication administration times or informing him of any delay in medications. NP 1 explained that if a medication is unavailable, it is acceptable to adjust administration times; however, there must be documented rationale for why the medication was not given as scheduled. During the same interview, NP 1 emphasized that if Resident 1’s morning medications—such as Alogliptin, Norvasc, Gabapentin, and Glipizide—were not administered as scheduled, medical complications could occur because these are critical medications. NP 1 stated he would expect licensed staff to notify him or MD 1 promptly if a resident, including Resident 1, would not receive medications on time so that appropriate adjustments could be made. During a telephone interview on 2/06/2026 at 2:44 PM, LVN 2 stated that on 2/05/2026 she spoke by phone with MD 2 because LVN 1, who was assigned to pass medications for both Residents 1 and 2, was running late. LVN 2 explained that the Director of Nursing (DON 2) asked her to call MD 2 to ask an order for an extension, as they anticipated LVN 1 would be delayed in administering morning medications to her assigned residents. LVN 2 could not recall the exact time of the call to MD 2 but estimated it was around 8:45 AM, while LVN 1 was in Resident 147’s room passing medications. LVN 2 stated she informed MD 2 that some of his patients would receive medications late but did not specify resident names or which medications during the call. During the same interview, LVN 2 acknowledged that she mistakenly believed both Residents 1 and 2 were under MD 2’s care and assumed MD 2 understood. LVN 2 stated she could not recall why she entered MD 1’s name in the physician order for Resident 1 when she only was able to speak to MD 2, (Resident 2’s attending physician). During the same interview, LVN 2 stated she had intended to call MD 2 again later that day to provide specific details such as name of medications, name of residents etc., but was unable to do so because she had to leave the facility early that day (2/6/2026). LVN 2 further stated she did not enter the physician order for the two-hour extension at the actual time of the call (around 8:45 AM) but entered at 10:45 AM. During the same interview, LVN 2 further stated she also did not inform Resident 1 and/or 2 and LVN 1 that an extension had been obtained for the administration of the AM medications. LVN 2 confirmed that the documented orders for Residents 1 and 2 were intended for the 9:00 AM medications but did not include a specific timeframe in the orders or the resident’s progress notes for the extension that indicated (from 9:00 AM up to 11:00 AM). 2. A review of Resident 2’s Admission Record (AC), the AC indicated Resident 2 was a 64 year old male admitted to the facility on 11/17/2025 with diagnoses that included Type 2 Diabetes Mellitus with unspecified complications, hypertension, encounter for orthopedic aftercare following surgical amputation, and acquired absence of left leg below knee. A review of Resident 2’s H&P dated 11/18/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. A review of a Resident 2’s MDS, dated 11/24/2025, the MDS indicated Resident 2 was cognitively intact. A review of Resident 2’s electronic physician order dated 2/5/2026 timed at 10:43 AM, authored by LVN 2, the order indicated a telephone order from MD 2 (Resident 2’s attending physician) indicating: “May extend AM med [medication] pass up to 2 hours.” The physician order lacked specific details, including which specific morning medications were to be extended and the exact timeframe for the extension (start and end times). During a telephone interview on 2/06/2026 at 10:30 AM, MD 2 stated she received a call from a facility nurse (LVN 2) on the morning of 2/05/2026, although she could not recall the exact time. MD 2 stated that LVN 2 informed her that LVN 1 was running late with the morning medication pass for her patients due to CDPH surveyors being present in the facility. MD 2 stated she instructed LVN 2 to call her back once the facility identified which residents under her care were affected and which specific medications were late or anticipated to be late, so that she could determine if any medication adjustments were necessary. During the same interview, MD 2 further stated she received another call later that evening, on 2/05/2026, informing her that Resident 2’s medications had already been administered late. MD 2 stated she then provided specific instructions and orders to adjust the administration times for Resident 2’s morning and evening medications. During an interview on 2/10/2026 at 1:42 PM, DON 2 stated that when medications are administered late, she expects licensed staff to communicate directly with the physician. DON 2 reported that on 2/05/2026 at approximately 9:45 AM, LVN 2 informed her that LVN 1 was going to be late with the medication pass for Resident 1. DON 2 stated LVN 2 informed her on 2/5/2026 that she had notified the physicians (for Residents 1 and 2) that a delay was anticipated and had asked whether the physicians wanted to extend the medication pass or hold the medications. During the same interview, DON 2 explained that LVN 2 checked Resident 1’s electronic MAR to identify which medications were marked in red, indicating they had not been administered and were past the scheduled time. Medications marked in yellow indicated there was still one hour remaining for administration. DON 2 stated LVN 2 did not follow up with Resident 1’s attending physician which is MD 1, to clarify which medications should be given or held for Resident 1. DON 2 emphasized that any physician order for an extension should have been specific and clearly indicated which medications were to be administered or held. 3. A review of Resident 3’s Admission Record (AR), the AR indicated Resident 3 was an 83 year old female originally admitted to the facility on 1/05/2026 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Alzheimer’s disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills). The AR listed FM 3 as Resident 3’s responsible party. A review of Resident 3’s History and Physical (H&P) signed and dated by Nurse Practitioner (NP) 1 on 1/12/2026, the H&P indicated the resident did not have the capacity to understand and make decision. A review of Resident 3’s Minimum Data Set (MDS, a resident assessment tool), dated 12/31/2025, the MDS indicated that Resident 147 has severely impaired cognition (the ability to process thoughts and emotions). A review of a physician order from PMHNP 1 dated 1/6/2026 timed at 1:06 PM, the physician’s order indicated to administer Imipramine 25 mg by mouth at bedtime for depression. The order was entered electronically and confirmed by DON 2 in Resident 3’s electronic medical record. A review of Resident 3’s “Psychotropic Medication Administration Informed Consent” for Imipramine 25 mg, a two-page document dated 1/06/2026 was reviewed. The first page included the following: the prescriber’s name was typed as PMHNP 1; the section labeled “Prescriber Signature” displayed a cursive-style typewritten signature for PMHNP 1, along with a handwritten date of 1/06/2026. The document further indicated, under the “Verified” section, DON 2’s handwritten name with a handwritten date of 1/06/2026. At the bottom of the document, Resident 3’s name was also handwritten. The second page of the document included the handwritten psychotropic medication name, Imipramine 25 mg, without FM 3’s name and signature. The document further indicated “The information above regarding the risk and benefits of psychotropic medication has been verbally explained to me and /or provided in writing..” A review of another physician order from PMHNP 1 dated 1/15/2026 timed at 4:38 PM, the physician’s order indicated to administer Trazodone 50 mg, one tablet by mouth at bedtime for depression manifested by difficulty sleeping. The order was entered electronically and confirmed by LVN 3 in Resident