Federal inspectors documented nurses falsely recording medication administration at Canyon Oaks Nursing and Rehabilitation Center, leaving a resident without prescribed bladder medication for over a week.
Canyon Oaks faces serious medication documentation violations discovered during February inspection, with nurses marking medications as "given" when drugs were unavailable.
Canyon Oaks Nursing Center: Staff Falsified Medication Records, Resident Denied Bladder Treatment for Week - California
Federal inspection reveals Canyon Oaks nurses documented administering unavailable bladder medication to Alzheimer's patient, creating dangerous gaps in treatment while family remained uninformed of medication shortage affecting resident's incontinence care.
Shocking: CA nursing home staff lied about giving meds while resident went without treatment for week
Canyon Oaks: Medication Documentation Fraud - CA
CANOGA PARK, CA - Federal inspectors documented systematic medication falsification at Canyon Oaks Nursing and Rehabilitation Center, where nursing staff repeatedly marked medications as administered when drugs were unavailable, leaving a vulnerable resident without prescribed treatment.
Nurses Falsified Medication Records for Week
The February 27, 2025 inspection revealed that Licensed Vocational Nurses (LVNs) at the facility documented giving Gemtesa, a bladder medication, to a resident with Alzheimer's disease, Parkinson's disease, and major depressive disorder between February 11-19, 2025, when the medication was actually unavailable.
According to the inspection report, Resident 112 required the medication for overactive bladder and urinary incontinence. The resident's physician had prescribed Gemtesa 75 milligrams daily, with medical notes indicating improvement in bladder spasms and urination while on the medication.
The falsification pattern emerged when inspectors reviewed the Electronic Medical Administration Record (EMAR), which showed conflicting documentation. While some nurses properly coded "3" indicating the medication was unavailable, others marked checkmarks falsely indicating the drug had been administered.
Pattern of Deceptive Documentation Discovered
The inspection revealed specific instances of false documentation: - February 12, 15, and 16: LVN 9 marked checkmarks indicating medication was given when it wasn't available - February 13-14: LVN 8 similarly marked false administration records - February 11, 17-19: Other nurses properly documented the medication as unavailable
When confronted, LVN 8 confirmed she "accidently check marked in the EMAR that Gemtesa was given" when the medication was unavailable. She acknowledged the importance of accurate charting so other nurses would know medication status.
LVN 9 admitted the check marks were documented in error and stated the EMAR is a legal document requiring accuracy for other nurses to know if residents received medications.
Family Left Uninformed of Treatment Gap
The medication shortage continued for over a week before family members were notified. LVN 4 revealed that when she spoke with the resident's family member on February 18, the family stated "he was never told in advance that the medication was out."
Proper medication management requires reordering when approximately seven tablets remain to account for insurance processing and delivery time. Registered Nurse 1 explained that if LVN 8 and LVN 9 had charted correctly, "Resident 112's may have received a replenished supply sooner."
Medical Implications of Bladder Medication Interruption
Gemtesa treats overactive bladder by relaxing bladder muscles and reducing urgent urination episodes. Sudden discontinuation can lead to return of bladder spasms, increased incontinence, and potential urinary tract complications, particularly concerning for elderly residents with cognitive impairment who may not communicate discomfort effectively.
The resident's care plan specifically aimed to keep them "clean, dry and free of odors" and reduce incontinence episodes. Missing medication for over a week directly undermined these established care goals and potentially compromised the resident's dignity and comfort.
Multiple Infection Control Failures Identified
Beyond medication falsification, inspectors documented several infection prevention violations that placed residents at risk:
Contaminated Food Storage: Inspectors found a day-old blueberry muffin left uncovered on Resident 96's bedside table. The Dietary Supervisor confirmed leftover food must be discarded after two hours as it becomes unsafe and may cause foodborne illness. The facility's policy prohibits residents from storing leftover meal tray items.
Oxygen Equipment Violations: Resident 345, who receives oxygen therapy for chronic obstructive pulmonary disease and respiratory failure, had oxygen tubing without required date labels. Facility policy mandates changing oxygen tubing weekly with proper labeling. The Director of Nursing confirmed this practice increases infection risk for residents.
Hand Hygiene Failures During Patient Care
Inspectors observed Treatment Nurse 2 failing to sanitize hands with alcohol-based hand rub after removing gloves during wound care for Resident 32, who had a feeding tube stoma requiring daily cleaning and dressing changes. The nurse acknowledged not understanding the requirement to sanitize hands each time gloves are removed.
Additionally, LVN 2 failed to wash hands before preparing and administering medications to residents. The nurse later admitted not following hand hygiene protocols, stating "hands are carriers of germs, and it was possible to spread infection if standard precaution was not practiced."
Policy Violations and Standards
The facility's own policies require objective, complete, and accurate documentation in medical records. The Charting and Documentation policy specifically mandates that medication administration be properly documented with specific details including date, time, provider name, and whether residents refused treatment.
The Handwashing-Hand Hygiene policy clearly states hand hygiene is "the primary means to prevent the spread of infection" and requires alcohol-based hand rub use after removing gloves and before handling medications.
Regulatory Response and Implications
The violations were classified as causing minimal harm or potential for actual harm, affecting few to some residents. However, the systematic nature of the medication documentation fraud and multiple infection control failures indicate broader systemic issues with nursing oversight and adherence to basic care standards.
Federal regulations require nursing homes to ensure residents receive prescribed medications as ordered and maintain infection prevention protocols to protect vulnerable populations. The combination of medication falsification and infection control failures at Canyon Oaks represents serious lapses in fundamental nursing home care standards.
The facility must submit a plan of correction addressing how it will prevent future medication documentation fraud and ensure proper infection prevention protocols are followed by all staff members.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Canyon Oaks Nursing and Rehabilitation Center from 2025-02-27 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.