complaint·October 1, 2025

On 10/01/25, LPA retrieved a copy of R1’s Morphine Record (08/04/25), Physician’s Reports (R2 – R6), Updated Training Record (S1) and interviewed Witnesses #1 - #2. Note: LPA left a message/voicemail to interview Witness #5 - # 6, #8 (09/17/25, 09/29/25), and Witness #9 - #10 (09/29/25). Investigation revealed the following: Allegation: Staff not qualified to give medication. Regarding the allegation, “Staff not qualified to give medication,” it is being alleged that Staff #1 was not qualified to administer R1’s medication. Record review of personnel policies revealed that each employee is required to have continuous training and applicable certificates in hospice care and proper handling of medication and required documentation. Medications’ policy and procedure revealed that two hours of hands-on-shadowing training will be provided prior to assisting with the self-administration of medication. Record review of staff training revealed S1 has zero (0) medication training in 2024 and three hours of medication training in 2025. Record review of hospice medication administration record revealed S1 administered R1’s medication on 08/05/25 10:30 AM. Regarding the allegation, “Staff not qualified to give medication,” based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. Health and Safety Code, Title 22, Division (6) and Chapter (03.2) are being cited on the attached LIC 9099D. An exit interview was conducted, plans of correction developed, and a copy of this report with appeal rights were provided to the Area Manager Irene Formentera. On 10/01/25, LPA retrieved a copy of R1’s Morphine Record (08/04/25), Physician’s Reports (R2 – R6), Updated Training Record (S1) and interviewed Witnesses #1 - #2. Note: LPA left a message/voicemail to interview Witness #5 - # 6, #8 (09/17/25, 09/29/25), and Witness #9 - #10 (09/29/25). Investigation revealed the following: Regarding the allegation, “Staff did not properly document resident's medications,” it is being alleged that staff could not locate the medication administration record to confirm if medication was administered to Resident #1 on 08/04/25. Record review of Morphine Record revealed medication was administered to R1 on 08/04/25 10:30 PM by S7. Interview with the Area Manager indicated that the record was placed in the back of the R1’s binder. A second medication record revealed medication was administered on 08/05/25 at 10:30 AM and at 11:13 AM. Regarding the allegation, “Staff did not properly document resident's medications,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation: Staff did not ensure resident was provided prescribed medications. Regarding the allegation, “Staff did not ensure resident was provided prescribed medications,” it is being alleged that staff did not provide medication A and B according to the doctor’s order. Record review of Hospice medication profile revealed medication A and B is to be given every hour as needed (08/04/25). Record review of Morphine Record revealed medication was administered to R1 on 08/04/25 10:30 PM by S7. Hospice medication profile revealed medication A and B is to be given every two hours, routinely (08/05/25). Hospice notes indicated that R1 received medication A on 08/05/25 at 10:30 AM and at 11:13 AM. Medication B was given on 08/05/25 at 11:13 AM. Interview with Hospice Agency (Witness #1) indicated that the medication was changed from as needed to routine on 08/05/25 around 10:30 AM. Record review of hospice documents revealed that R1 passed away on 08/05/25 12:13 PM. Regarding the allegation, “Staff did not ensure resident was provided prescribed medications,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Continue to LIC9099-C. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Area Manager Irene Formentera.