The resident, identified as Resident 3 in inspection records, was prescribed apixaban on October 5th to prevent blood clots related to atrial fibrillation, a heart rhythm disorder. The 2.5 mg daily dose requires careful monitoring because anticoagulant medications can cause serious bleeding complications.
But when federal inspectors arrived October 10th, they found no care plan existed for the medication despite facility policy requiring comprehensive plans for each resident's needs.
The facility's own policy, revised in December 2016, states that "a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident."
Nobody took responsibility.
RN 1, interviewed while reviewing the resident's medical record, confirmed the physician's order existed and acknowledged no care plan had been developed. She told inspectors she wasn't responsible for creating medication care plans upon admission.
Instead, RN 1 said the Director of Nursing, Assistant Director of Nursing, and Medical Records Director were supposed to audit new admissions for completion.
The Medical Records Director shifted responsibility to others. She told inspectors she reviewed new admission charts for medication entries and baseline assessments, but said "the ADON and MDS Coordinator would be responsible in reviewing and initiating the care plan for medications."
LVN 2 understood the stakes. When asked about anticoagulant care plans, the licensed vocational nurse explained that "anticoagulant medications must have a care plan to show goals and interventions such as monitoring for side effects and re-assess outcomes."
The MDS Coordinator, responsible for resident assessments, acknowledged the failure when interviewed at 2:03 p.m. She told inspectors that care plans for anticoagulant use "must be initiated as soon as possible" and verified that Resident 3's medical record contained no such plan.
Apixaban, marketed as Eliquis, belongs to a class of newer blood thinners that prevent stroke in patients with atrial fibrillation. While generally safer than older anticoagulants like warfarin, the medication still requires monitoring for bleeding complications, drug interactions, and effectiveness.
The resident had full decision-making capacity according to a health and physical examination dated October 7th, three days before inspectors arrived. This meant the person could have participated in developing treatment goals and understanding medication risks if a care plan had existed.
The facility's comprehensive care plan policy requires the Interdisciplinary Team to work "in conjunction with the resident and his/her family or legal representative" to develop individualized plans. Without this process, the resident received medication management that failed to meet federal standards for person-centered care.
Director of Nursing was informed of the findings during a 3:36 p.m. interview on October 10th and acknowledged the deficiency.
The inspection report notes this failure "had the potential for the resident to not be provided with appropriate, consistent, and individualized care." Federal regulations require nursing homes to develop care plans that address each resident's specific medical needs with measurable objectives and timelines.
Villa Valencia Healthcare Center, located at 25000 Calle De Los Caballeros, operates under California's oversight but must meet federal Medicare and Medicaid standards. The facility's failure affected what inspectors classified as "some" residents, though only one case was detailed in the violation.
The missing care plan meant no formal system existed to track whether the blood thinner was working effectively, monitor for dangerous side effects like internal bleeding, or coordinate with other medications the resident might be taking. Such oversights can lead to medication errors, missed symptoms of complications, or inadequate response to bleeding emergencies.
Five days passed between the medication order and the inspection. During that time, nursing staff administered a powerful anticoagulant without the safety framework their own policies required.
The resident continued taking apixaban while facility administrators scrambled to explain who should have created the missing care plan that nobody did.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Villa Valencia Healthcare Center from 2025-10-10 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Villa Valencia Healthcare Center
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