Terrabella Northridge

The facility failed to properly administer insulin to a resident, specifically failing to prime insulin pens with a 2-unit air dose and failing to check expiration dates. Medication aides administered expired Lantus and ASPA insulin pens that had expired on 03/25/25. These errors occurred during medication passes observed on 03/26/25 and 03/27/25.

The facility failed to properly administer medications as ordered for one resident, specifically involving errors with insulin administration. Observations revealed a medication error rate of 8% during morning medication passes, including failures to follow manufacturer instructions for priming insulin pens.

The facility failed to ensure that one resident and three other residents reviewed during medication pass had a current FL-2 medical examination completed annually. Specifically, Resident #4's medical examination had not been updated since September 2023.

The facility failed to ensure that residents had current annual medical examinations (FL-2) completed. Specifically, one resident and three residents from a medication pass observation were found to have outdated medical documentation.

The facility failed to ensure the routine and acute health care needs of a resident were met. Specifically, staff failed to notify the resident's primary care provider or emergency department regarding a right knee deformity, swelling, and pain. This lack of follow-up resulted in a diagnosed closed fracture of the distal end of the right femur.

The facility failed to ensure the routine and acute health care needs of a resident were met. Specifically, staff failed to notify the resident's primary care provider, utilize on-call services, or transport the resident to the emergency department for a right knee injury involving swelling, pain, and leg deformity.

The facility failed to implement and document physician-ordered dental care for a resident. Specifically, there was no evidence in the electronic medication administration records that the resident was being assisted with brushing teeth three times daily, removing her upper partial denture at night, or using a prescribed oral gel rinse.