WOODLAND HILLS, CA - Federal inspectors documented serious medication errors, infection control breaches, and food safety violations at Motion Picture and T.V. Hospital's skilled nursing facility during an April 2025 inspection.
Discontinued Medication Administered for Multiple Days
The most significant violation involved staff repeatedly administering discontinued medication to a vulnerable resident with a stage-2 pressure wound. Resident 39, who has dementia and requires total assistance with daily activities, received mupirocin ointment for wound treatment even though the medication order was discontinued on February 12, 2025.
Licensed Vocational Nurse (LVN) 1 admitted to administering the discontinued medication on April 7, 8, 9, and 10, 2025. During the inspection observation, LVN 1 applied mupirocin ointment to the resident's sacral pressure wound, then later discovered there was no active order for the medication.
Medical Impact of Improper Medication Administration
Mupirocin is an antibiotic ointment typically prescribed for short-term use to prevent bacterial infection in wounds. When discontinued medications remain accessible, staff may inadvertently continue treatments that are no longer appropriate or effective. In this case, the discontinued mupirocin could have interfered with the resident's prescribed healing regimen or delayed proper wound recovery.
The facility's Director of Long Term Care acknowledged that discontinued medications are removed for specific medical reasons - either because they're no longer effective or because a different treatment approach is more appropriate. Continuing inappropriate medication treatments can negatively impact healing processes and resident outcomes.
Widespread Infection Control Failures
Inspectors observed multiple staff members failing to follow proper infection prevention protocols, potentially exposing residents to communicable diseases and infections.
Droplet Precaution Violations
Activities Assistant 1 entered the room of Resident 47, who was under droplet precautions for respiratory symptoms, without wearing required protective equipment. The resident's door displayed clear signage indicating droplet precautions and requiring a surgical mask, but the staff member failed to read the sign and entered without protection.
Droplet precautions are essential for preventing transmission of respiratory illnesses like influenza and COVID-19. The protocols require staff to wear masks when within six feet of residents showing respiratory symptoms.
Enhanced Barrier Precaution Breaches
Multiple staff members violated Enhanced Barrier Precaution (EBP) protocols designed to prevent transmission of drug-resistant organisms. These violations occurred with residents who had feeding tubes and pressure wounds - conditions that increase infection transmission risk.
During resident transfers and personal care activities, CNAs failed to wear required isolation gowns when caring for residents under EBP protocols. These precautions are specifically designed for high-contact activities including dressing, bathing, transferring, and wound care.
Food Safety Deficiencies Create Health Risks
Kitchen inspections revealed multiple food safety violations that could lead to bacterial contamination and foodborne illness affecting 88 of the facility's 89 residents.
Improper Food Storage and Labeling
Inspectors found several concerning food storage practices:
- Personal coffee cup belonging to kitchen staff placed on food preparation equipment - Opened food packages lacking required date labels - Misidentified food containers (brown rice labeled as black-eyed peas) - Wet storage conditions for potatoes that could promote bacterial growth
The Director of Hospitality Services confirmed these violations could lead to cross-contamination and bacterial growth. Federal food safety guidelines require proper labeling of opened packages to track freshness and prevent spoilage, while personal items must be kept separate from food preparation areas.
Medical Record Documentation Failures
The facility failed to complete required discharge summaries for therapy services, creating gaps in resident care documentation. Physical therapy and occupational therapy discharge summaries were missing for two residents after their treatment programs ended in early 2025.
These discharge summaries are crucial for documenting resident progress, functional capabilities, and ongoing care recommendations. Missing documentation can result in inappropriate care plans and missed opportunities for continued therapeutic interventions.
Antibiotic Stewardship Concerns
Inspectors identified concerning antibiotic prescribing practices involving long-term azithromycin use for pneumonia prevention. The facility's antibiotic stewardship program failed to adequately review this atypical prescription, which lacked clear clinical justification and had no predetermined end date.
Inappropriate antibiotic use contributes to the development of drug-resistant bacteria and can cause adverse side effects in elderly residents. Proper antibiotic stewardship requires regular review of all antibiotic prescriptions to ensure appropriate indications and durations.
Regulatory Response and Industry Standards
These violations represent failures in fundamental nursing home safety protocols. Federal regulations require facilities to maintain proper medication administration procedures, implement effective infection control programs, ensure food safety standards, and maintain accurate medical records.
The Centers for Medicare & Medicaid Services classifies these violations as having potential for actual harm, indicating serious deficiencies in resident care and safety systems. Facilities must demonstrate immediate corrective actions to address identified violations and prevent recurrence.
Motion Picture and T.V. Hospital's skilled nursing facility must submit detailed correction plans addressing each violation area. The facility's policies were adequate, but implementation and staff compliance with established procedures failed to meet federal standards.
Nursing homes serving vulnerable populations must maintain rigorous safety protocols to protect residents from preventable harm. These inspection findings highlight the critical importance of staff training, policy enforcement, and systematic quality assurance programs in long-term care facilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Motion Picture and T.v. Hosp D/p Snf from 2025-04-11 including all violations, facility responses, and corrective action plans.
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