complaint·January 21, 2026

The investigation revealed the following: Allegation: Unqualified facility staff administered medication to resident It was alleged that an unqualified facility staff administered liquid narcotic medication to the resident at least two times in the middle of the night (late night 10/30/2025 or early morning 10/31/2025), following the first dose given to Resident 9 (R9) by their hospice nurse on the evening of 10/30/2025. On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs and LVNs are authorized and trained to administer medication at the facility. A1 also stated the procedure for giving medication to hospice residents, especially after hours, is per the doctor's orders. A1 mentioned there have not been any situations where a staff member who is not medication certified gave medication to a resident, and all new staff are medtech certified. On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm - 3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 2 of 10 staff were aware of the allegation, of which 1 staff member stated Resident 9 (R9)'s relative mentioned Staff 11 (S11) who administered narcotic medication mixed together with another medication. 1 of 10 staff was unaware of the allegation and stated not having knowledge of a staff who is not medication certified administering medication to a resident. 7 of 10 staff denied the allegation, of which 2 staff have never witnessed a staff who is not medication certified administering medication to a resident, while 1 staff is a medtech who ensures to read medication labels and dosages while administering medication but does not have any knowledge of what occurs after hours due to not being scheduled during that time period. On 11/17/2025 between the hours of 2:05pm - 3:00pm, then on 12/02/2025 between the hours of 1:21pm - 3:40pm and on 01/26/2026 between the hours of 9:30am -10:22am, LPA conducted 9 interviews with residents regarding the allegation. 1 of 9 residents did not confirm nor deny the allegation and stated staff does not identify nor verify what medications are being given. The medtech just watches to ensure medication is taken. 1 of 9 residents confirmed the allegation, stating that in the past couple of days medication was administered at 10pm by the medtech. 7 of 9 residents denied the allegation and stated not witnessing staff giving medication late at night or at times when the nurse, medtech, or hospice workers are not present. However, 1 of the 7 residents expressed wanting more communication and explanation regarding what the medication is for and why the medication needs to be taken. On 01/20/2026 between the hours of 2:58pm -3:20pm, LPA conducted a records review and observed the following for Resident 9 (R9) Medication Administration Record (MAR) for the month of October 2025. On 10/30/2025 and 10/31/2025 it was not marked off on the MAR that narcotic medication (morphine) SULF 100 mg/5 ML CONC was administered to the resident. Also, LPA observed that the department did not receive a LIC 624: Unusual Incident/Injury Report via fax in regards to R9 receiving a double dosage of narcotic medication which caused R9 to overdose and the facility administering the Narcan to sedate the resident. Investigation findings continue on LIC 9099-C On 01/21/2026 between the hours of 12:10pm -12:15pm, LPA conducted a records review and observed the following: According to the Physician Order from Committed Hospice Care Inc for List of New/Refill Order, Start date 10/28/2025 for Morphine Sulfate 15 mg tablet with a dosage of 0.5 tablet oral every 4 hours as needed for pain and discontinue on 10/31/2025. Start date 05/25/2025 for Morphine Sulfate 20mg/1mL Solution with quantity 30 ml and a dosage of 0.25ml (5mg) oral every 4 hours as needed for severe pain and discontinue on 10/31/2025. Start date 10/30/2025 for Lorazepam 1 mg with the start date 10/30/2025 with 1 tablet dosage oral to be given 2x daily at 9am and 5pm for anxiety and restlessness and discontinue on 10/31/2025. On 01/21/2026 between the hours of 9:10am -10:31am, LPA at the time requested a copy of Staff 11 (S11) medication administration training and, the facility was unable to provide proof of medication certification for Staff 11 (S11). Based on LPA's interviews and record review, Staff 11 administered medication to Resident 9 which resulted in R9 overdosing on medication and facility staff administering Narcan. Staff 11 does not have any documented training for medication administration. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Allegation: Facility staff did not seek timely medical attention for resident It was alleged that facility staff did not seek timely medical attention for a resident following an overdose of medication and the administration of Narcan. On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated the process upon finding a resident unresponsive or in distress is to promptly contact emergency first responders for residents who experience a medical problem or need urgent help. Regarding the actions taken on the morning of 10/31/2025, A1 stated calling hospice and declared the decision made about calling emergency responders. Investigation Findings continues on LIC 9099-C On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm -3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 4 of 10 staff were aware of the allegation and stated being informed about what had occurred with Resident 9 (R9). 2 of 10 staff did not confirm nor deny the allegation, with 1 of the staff stating being scheduled to work on the evening of 10/31/2025 and explaining the process of what decision should be made about calling 911 or administering Narcan. The other staff said upon observing Resident 9 (R9), who appeared to be heavily sedated and drooling, a medtech made the decision to administer Narcan. 4 of 10 staff were unaware of the allegation, with 1 staff stating this is a question for the medtech, while the other 3 staff stated not being scheduled to work on the day of the incident. On 11/17/2025 between the hours of 2:05pm - 3:00pm, then on 12/02/2025 between the hours of 1:21pm -3:40pm and on 01/26/2026 between the hours of 9:30am - 10:22am, LPA conducted 9 interviews with residents regarding the allegation. 3 of 9 residents confirmed the allegation, with 1 of the 3 residents stating they have witnessed a delay with resident health concerns regarding their neighbor. 6 of 9 residents denied the allegation. Out of the 6 residents who denied the allegation, 4 of those residents expressed the facility staff calls for outside assistance from emergency first responders right away. On 01/21/2026, LPA conducted a record review between the hours of 12:00pm -12:05pm, and observed the following: Resident 9 (R9)'s communication log (dated 10/30/2025) by Staff 11 states resident declined medical attention, confirmed and spoke with R9 family member by phone and in person. On 01/20/2026, between the hours of 4:25pm - 4:30pm, LPA conducted a records review and observed the following: the department did not receive a LIC 624: Unusual Incident/Injury Report via fax in regards to R9 being transported by emergency first responder nor R9's refusal of wanting to go to the hospital in regard to overdose and the administration of Narcan. Based on the LPA conducting interviews and records review, the facility failed to seek timely medical attention when the resident appeared to be in distress and waited until an hour later to administer Narcan. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Investigation Findings continues on LIC 9099-C Allegation: Facility staff did not properly report incident On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated the steps staff are required to take when a resident has a serious incident that occurs such as an overdose is to call 911. Also, A1 stated medtech and LVN are responsible for notifying the representative, hospice, and licensing after an incident occurs. In the event something unusual or unsafe happens, staff communicate by phone notification and folders for shift to shift communication. A1 mentioned not witnessing staff failing to document and or follow up on an incident. On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm -3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 7 of 10 staff denied the allegation. 2 of 10 staff confirmed the allegation with 1 staff stating witnessing the LVN all the time failing to document and or follow up on incidents that occur. 1 of 10 staff was unaware of the allegation, not knowing if the medtech and LVN conduct follow up in regards to incidents that occur. On 11/17/2025 between the hours of 2:05pm - 3:00pm, then on 12/02/2025 between the hours of 1:21pm -3:40pm and on 01/26/2026 between the hours of 9:30am -10:22am, LPA conducted 9 interviews with residents regarding the allegation. 1 of 9 residents confirmed the allegation and stated they have witnessed staff failing to document or follow up on an incident. 4 of 9 residents denied the allegation, stating that the facility handles emergency and incident reporting well. 2 of 9 residents were unaware of the allegation due to not having any idea nor any knowledge of how the facility handles emergency/incident reporting. 2 of 9 residents did not confirm nor deny the allegation with 1 of the residents stating not knowing nor never really having an emergency while the other resident stated the facility sometimes handles emergency or incident reporting. Investigation Findings continue on LIC 9099-C On 01/21/2026 between 10:03am -10:05am, a records review was conducted. Upon review of Resident 9 (R9)'s communication logs dated 10/30/2025 and 10/31/2025, the following was observed: Staff 11 (S11) created an entry at 6:39am, which was last updated by Staff 5 (S5). The entry indicated that hospice was called and a nurse assisted R9 due to severe seizures and aftershocks, and morphine liquid and Ativan were administered. At 6:56pm on 10/30/2025, R9 experienced 4 seizures within 1 hour. At 7:03pm on 10/30/2025, per the hospice RN, updated orders were issued: Lorazepam (Ativan) 1 mg Q4H "Give 2 tabs of 0.5 mg PO Q4H" and Norco 5-325 mg Q6H "Give 1 tab PO Q4H" for 24 hours starting at 9:00pm on 10/30/2025. The hospice RN left a written order in the medication room. S11 documented at 8:20am on 10/30/2025 that R9 declined medical attention after staff confirmed and spoke with their family member by phone and in person, noting that R9 did not want to go to the hospital for any medical attention. S5 created an entry on 10/31/2025 at 9:55am, updated at 1:28pm, stating that R9 was found on the floor around 8:30am by Resident 4 (R4), who is R9's next-door neighbor. R4 discovered injuries on R9's right arm and knee, and R9 exhibited weakness in their legs. Hospice was notified, and the nurse instructed staff to hold the Lorazepam at 9:00pm due to R9's weakness. A medtech aide created an observation/progress note at 7:25am on 10/31/2025, indicating that R9 was okay during the NOC shift from 10:30pm - 6:30am with no seizures, and that R9 took his Ativan at 1:00am and 5:00am. S5 documented at 9:55am on 10/31/2025 that R9 was vomiting with increased confusion and slurred speech. Narcan was administered, hospice was notified about the change in condition, and staff spoke to case management requesting updated medication orders due to R9 being on routine narcotics and the medication change on 10/30/2025. The nurse stated they would assess the resident and requested a faxed order. On 01/20/2026, between the hours of 4:25pm - 4:30pm, LPA conducted a records review and observed the following: the department did not receive a LIC 624: Unusual Incident/Injury Report via fax in regards to what happened on 10/30/2025 nor 10/31/2025 with R9 being administered incorrect dosage of medicine and also there is no evidence to support the responsible party of R9 was notified in regards to this incident. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. Investigation Findings continues on LIC 9099-C Allegation: Facility staff did not answer resident's call button in a timely manner It was alleged that facility staff did not answer the resident's call button in a timely manner between the dates of 10/30/2025-10/31/2025. It is also alleged that the resident had pulled their cord on the call light in the early morning of 10/31/2025 but no one came, so the resident attempted to get out of bed and fell at breakfast time, when staff found the resident on the floor. On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated call buttons and or monitored resident checks, especially for those on hospice, are a standard every 2 hours and as needed. The usual response time is promptly but there are not any logs on file. A1 also stated not being aware of any challenges with responding to call lights promptly. On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm -3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 2 of 10 staff confirmed the allegation, of which 1 of the staff stated sometimes there have been challenges with responding to the call light due to staff being short-staffed. 8 of 10 staff denied the allegation and expressed caregivers go immediately to attend to the resident's needs within 5-10 minutes and or once the beeper/pager goes off, an announcement is made over the walkie talkie for a caregiver to go assist the resident who called for help. On 11/17/2025 between the hours of 2:05pm - 3:00pm, then on 12/02/2025 between the hours of 1:21pm - 3:40pm and on 01/26/2026 between the hours of 9:30am -10:22am, LPA conducted 9 interviews with residents regarding the allegation. 3 of 9 residents did not confirm nor deny the allegation due to not using the call button. 4 of 9 residents confirmed the allegation and stated not using the call button since the staff would never come to help them so they would go to the staff for help. 2 of 9 residents denied the allegation and stated by 1 of the residents who expressed not calling for help while the other resident stated not waiting a long time for someone to respond. On 01/20/2026, between the hours of 4:25pm-4:30pm, LPA conducted a records review and observed the following: the department did not receive a LIC 624: Unusual Incident/Injury Report via fax in regards to R9 falling out of the bed which resulted in R9 being found on the floor. However, in R9's communication log (provided on 01/21/2026) it states the on 10/31/2025, R9 was found on the floor around 8:30am by R4 who is R9's next door neighbor. Injuries appeared on R9's right arm & knee as well having weakness on legs. Investigation Findings continue on LIC 9099-C On 01/21/2026, between 9:44am - 10:44am, the LPA conducted a call light button test in the following rooms: Room 105 from 9:44am - 10:22am, Room 104 from 10:22am - 10:32am, and Room 114 at 10:34am - 10:44am. It was observed that call light lit up and made a beep sound and staff did not come into any of these 3 rooms to answer the call light button. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. At this time, an Enhanced Civil Penalty determination is pending in reference to Health & Safety Code 1569.49(f) "Serious Bodily Injury" as defined in Section 243 of the Penal Code that states, "a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement." Civil Penalty: Exit interview conducted with Joel Niblett (Administrator) and a copy of this report was provided with appeal rights. The investigation revealed the following: Allegation: Facility staff did not follow resident's care plan It was alleged that facility staff did not follow the resident's care plan in which staff are supposed to check on the resident every 30 minutes but they do not. On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 did not confirm nor deny the allegation in regard to staff are to stay update on each resident's care plan, especially those on hospice, by reviewing the hospice folder. A1 expressed staff are supposed to check on residents who require regular monitoring every 2 hours as needed. A1 also mentioned a resident care plan's instructions are to be followed consistently across all shifts with a communication log in place.. A1 stated not applicable, no monitoring log, in regards to staff ensuring that entries in resident records reflect what actually occurred. Also A1 mentioned staff document according to their observation and it's not applicable in regards to there have not been any issues maintaining accurate logs or completing them on time. On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm -3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 1 of 10 staff confirmed the allegation and stated the facility doesn't really have a proper system and expressed not enough information is documented in the communication log in regards to staying updated with the resident care plan. 9 of 10 staff denied the allegation and expressed staff stay up to date with resident's care plan by using August Health, communication logs/notes, and verbal crossover exchange. On 11/17/2025 between the hours of 2:05pm-3:00pm, then on 12/02/2025 between the hours of 1:21pm -3:40pm and on 01/26/2026 between the hours of 9:30am -10:22am, LPA conducted 9 interviews with residents regarding the allegation. 1 of 9 residents confirmed the allegation and stated staff do not seem to follow each resident's care plan. 5 of 9 residents denied the allegation and expressed the staff is understanding of the resident's care needs. 3 of 9 residents did not confirm nor deny the allegation and stated some staff understand the care needs of the resident while other staff do not. Investigation findings continues on LIC 9099-C On 01/21/2026 between the hours of 1:15pm -1:25pm, LPA conducted a records review and observed the following: According to Committed Hospice Care Inc - Plan of Care (dated 05/27/2025) for Resident 9 (R9) on page 9 of 11, for pain goal: in 1-2 weeks, patient's pain level remains <3 and maintains comfort/satisfaction from pain after nursing intervention/medication. PT/PCG will verbalize/express understanding of medication/treatment orders and side effects. Intervention states administer medication as ordered: Norco 5-325mg oral 1 tab every 6 hours as needed for moderate-severe pain (5-10/10). Morphine Sulfate 20mg/1mL Solution oral 0.25ml (5mg) every 4 hours as needed for severe pain (7-10/10). Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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. Therefore, the allegation is UNSUBSTANTIATED . Allegation: Facility staff did not keep accurate resident records It was alleged that facility staff did not keep accurate resident records when staff used to keep a log in the resident's bedroom to initial every 30 minutes, but staff would write down several "checks" in a row that never actually occurred, so they removed it. On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 did not confirm nor deny the allegation and stated staff document according to their observation when asked how staff ensure that entries in resident records reflect what actually occurred. A1 said not applicable when asked if there have been any issues to maintaining accurate logs or completing them on time. Also, A1 mentioned not applicable, no monitoring log when asked how check-ins, observations, or monitoring logs are documented for residents who require frequent checks. On 11/17/2025 between the hours of 10:02am-12:52pm and on 12/02/2025 between the hours of 12:26pm -3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 3 of 10 staff confirmed the allegation and expressed there have been issues with the resident's records not being accurate. 6 of 10 staff denied the allegation and stated there have not been any issues maintaining accurate logs for the resident records. 1 of 10 staff was unaware of the allegation and stated not being aware of any issues of completing and maintaining accurate logs on time. Investigation Findings continue on LIC 9099-C On 11/17/2025 between the hours of 2:05pm-3:00pm, then on 12/02/2025 between the hours of 1:21pm - 3:40pm and on 01/26/2026 between the hours of 9:30am - 10:22am, LPA conducted 9 interviews with residents regarding the allegation. 3 of 9 residents denied the allegation. 3 of 9 residents confirmed the allegation and stated not witnessing staff writing and or logging information in regard to care and regular routine checks. 3 of 9 residents did not confirm nor deny the allegation and stated sometimes witnessing staff writing and or logging information in regard to care and regular routine checks. Based on observation and records review conducted on 01/21/2026 between the hours of 1:35pm -1:40pm, in R9's hospice care plan, it does not state the resident should be checked on every 30 minutes. Also, upon observation and record review, the facility does not have a check log on file. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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. Therefore, the allegation is UNSUBSTANTIATED . Exit interview conducted with Joel Niblett (Administrator) and a copy of this report was provided .