SUN VALLEY, CA - A January 2025 federal inspection of Pacifica Hospital of the Valley Dp Snf uncovered multiple deficiencies including controlled substance documentation failures, infection control violations, unsigned physician orders, and pharmaceutical service gaps affecting numerous residents at this skilled nursing facility.
Controlled Medication Records Failed to Match Administration Logs
Federal surveyors identified significant discrepancies between controlled drug records and medication administration records for residents receiving narcotic pain medications, raising concerns about proper pharmaceutical oversight at the facility.
For one resident with respiratory failure who was severely cognitively impaired and dependent on staff for daily care, investigators found that the narcotic pain medication Norco (hydrocodone-acetaminophen) had been removed from blister packs on four separate occasions in late January 2025, but no corresponding entries appeared in the medication administration record. The controlled drug record showed the medication was signed out on January 28 at 4:20 a.m., January 26 at 6 a.m., January 24 at 6 a.m., and January 23 at 11 p.m.
Similarly, the anti-anxiety medication lorazepam (Ativan) was documented as removed from stock on January 24 at 3 a.m. and January 23 at 9 p.m. for the same resident, yet the medication administration record contained no documentation that these medications were actually given.
A second resident with acute respiratory failure and a diagnosis of pain showed the same pattern. The controlled drug record indicated Norco was signed out on January 24 at 9 p.m., but the medication administration record contained no entry for that date and time.
When controlled substances are removed from stock but not documented as administered, it creates uncertainty about whether residents actually received their prescribed pain relief. It also prevents physicians from accurately assessing whether pain management protocols are effective, since pain levels before and after medication cannot be tracked.
The Director of Nursing acknowledged the documentation gaps during the inspection, stating the facility "did not think there was an issue of drug diversion" but confirmed that without medication administration record entries, "the pain was not assessed for those times." The Director of Staff Development added that proper documentation "was important to know if the pain medication was effective, and if not effective to notify the doctor to receive an order to modify the dosage."
The facility's own policies explicitly require nurses to complete both the controlled drug accountability record and the medication administration record after giving medications. The policy states that "entering information on the accountability record does not replace recording medication administration on the MAR."
Emergency Medication Kits Not Replaced Within Required Timeframe
Surveyors found that emergency medication kits in two medication storage rooms had been opened weeks before the inspection but never replaced, potentially leaving the facility without critical medications for seizure emergencies.
In one unit's medication refrigerator, the emergency kit that originally contained three vials of Ativan (used to treat active seizures) was missing two vials. Records showed one vial was used on December 24, 2024, and another on January 14, 2025, for residents experiencing seizure episodes. However, as of the January 28, 2025 observation, the kit had not been replaced despite facility policy requiring replacement within 72 hours of opening.
In another unit, surveyors observed an emergency kit missing one vial of Ativan used on January 10, 2025. The charge nurse was unable to locate the usage log and was unsure when the medication was used or for which resident.
When emergency medications are unavailable, residents experiencing medical crises may face delays in receiving life-saving treatment. For seizure disorders, rapid administration of anti-seizure medication can be critical to preventing prolonged seizure activity, which can cause brain damage or death.
Infection Control Practices Found Deficient Across Multiple Areas
The inspection identified several failures in infection prevention protocols, including staff entering isolation rooms without proper protective equipment and failing to perform hand hygiene after patient contact.
A housekeeper was observed entering a resident's room that had contact isolation precautions posted on the door without wearing a gown. The resident was on isolation for carbapenem-resistant Enterobacterales (CRE) and Extended-Spectrum Beta-Lactamases (ESBL), both serious drug-resistant organisms. After collecting trash from the room, the housekeeper removed his gloves and left without performing hand hygiene.
Separately, two licensed vocational nurses were observed administering tube feedings and medications to residents on enhanced barrier precautions without wearing protective gowns. Enhanced barrier precautions require gowns and gloves during high-contact care activities such as feeding tube use to prevent the spread of multi-drug resistant organisms.
One nurse acknowledged after the observation that she "was not aware that she has to wear a gown when using a g-tube to administer bolus feeding or medication" to prevent infection spread.
Drug-resistant organisms like CRE can cause severe infections that are extremely difficult to treat with available antibiotics. When healthcare workers fail to follow isolation precautions, these organisms can spread to other vulnerable residents through contaminated hands or clothing.
Physician Orders Lacked Required Signatures and Dates
For three residents, surveyors found physician orders in paper records that lacked dates, times, or physician signatures, violating documentation requirements designed to ensure orders are current and traceable.
One resident with respiratory failure and seizure disorder had multiple unsigned telephone orders including recommendations for physical therapy evaluation, restorative nursing programs, range of motion exercises, and orthotic device applications. None of these orders contained the physician's signature.
Another resident had numerous undated orders including prescriptions for weight loss medication, laboratory tests, allergy medications, and diagnostic imaging studies. Without dates, it becomes impossible to determine when these orders were written or whether they remain current.
The Director of Nursing confirmed that physicians must date and time their orders, noting that "if the order is not entered directly into the electronic health record system the day the order was taken, there could be a delay in care for a resident."
Proper order documentation establishes a clear timeline for treatment decisions and ensures that all members of the care team understand current treatment plans. Unsigned or undated orders can lead to confusion about whether treatments should be implemented and may delay necessary care.
Pharmacist Recommendations Not Acted Upon
The facility failed to follow up on consultant pharmacist recommendations for two residents, leaving potential medication concerns unaddressed for months.
For one resident who had been receiving the iron supplement FeroSul since April 2021, the pharmacist's October 2024 medication regimen review recommended reassessing the need for continued therapy. At the time of the January inspection, no documentation showed that the resident's physician had been contacted about this recommendation.
For another resident taking the seizure medication levetiracetam (Keppra), the pharmacist recommended ordering blood level testing to monitor drug levels. This recommendation, made in September 2024, had not been acted upon by the time of the inspection more than four months later.
Blood level monitoring for seizure medications helps ensure therapeutic drug concentrations and identify potential toxicity. Without this monitoring, residents may receive suboptimal doses that fail to control seizures or excessive doses that cause adverse effects.
Medication Storage and Labeling Deficiencies
Surveyors found multiple medication storage violations including unlabeled opened medications and discontinued medications still stored in medication carts.
An opened potassium chloride solution lacked an open date, making it impossible to determine whether the medication remained within its beyond-use period. A discontinued chlorhexidine oral solution remained in a medication cart despite having no current order for the resident. An opened container of Vitamin A and D ointment had no label indicating when it was opened.
The Director of Staff Development confirmed that medications without current orders "should be removed from the medication cart" to "avoid possible medication error such as a resident accidentally receiving the unordered medication."
Additional Issues Identified
Beyond the major violations detailed above, the inspection documented several additional deficiencies:
- Social services assessment delays: One resident admitted in September 2024 had not received a social services assessment by the time of the inspection, more than four months later. The social worker acknowledged being "backed up with assignments" and stated the delay could affect addressing "psychosocial issues and assisting the residents with their adjustment period."
- Psychotropic medication monitoring failures: A resident receiving the antidepressant Cymbalta had no documentation that staff were monitoring for potential side effects as required by the care plan, despite receiving the medication daily for at least 11 consecutive days.
- Food storage violations: Frozen pork chops and fish sticks in the facility's freezers lacked required date labels, preventing staff from determining how long the items had been stored.
- Staffing data submission failures: The facility failed to submit required staffing information to federal regulators for two consecutive fiscal quarters in 2024. The Director of Staff Development stated the person responsible for submissions was on medical leave and previous administrators who had portal access were no longer employed by the facility.
The inspection findings indicate systemic issues with documentation practices, pharmaceutical oversight, and infection control compliance at the facility. Federal regulations require nursing homes to maintain accurate medication records, follow infection prevention protocols, and ensure timely implementation of physician orders and pharmacist recommendations to protect resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pacifica Hospital of the Valley Dp Snf from 2025-01-30 including all violations, facility responses, and corrective action plans.
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