Complaint·October 7, 2025

LPA reviewed the Department's documents, although, a death report was submitted to CCLD, no incident reports were submitted to CCLD in regards to R1's falls, and the facility was unable to provide fax confirmation sheets to show that incident reports were submitted to CCLD. Based on the interviews conducted, records reviewed and information collected, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator, Anne Buerhaus and a copy is provided with appeal rights. During the investigation, LPA reviewed R1's file, interviewed staff, and interviewed hospice notes. According to staff interviewed and documents reviewed, R1 had 8 falls within 8 months, and the facility implemented frequent checks that were being conducted every 1-2 hours, in addition to close supervision by bringing R1 into the common area. The facility also removed all fall hazards from R1's room and placed a fall mat in R1's room. Based on R1's file, after each fall, the facility would reach out to hospice and R1's physician for medication adjustments. Regarding the allegation, medication was not administered as prescribed, according to the reporting party, R1 was experiencing anxiety and agitation and was prescribed morphine on an as needed basis to control this condition. Reporting party indicated that the facility was not administering the morphine when R1 needed it. During the course of the investigation, LPA conducted interviews, conducted research, and reviewed pertinent documents related to the allegation. According to interviews and documentation reviewed, there are two Registered Nurses (RNs) and one Licensed Vocational Nurse (LVN) at the facility who were able to provide morphine to R1 as needed as prescribed by the physician, however based on interviews conducted, R1 did not require morphine until he/she was transitioning to hospice and that's when morphine was being prescribed by hospice. In addition, staff interviews indicated that morphine was on standby. Based on interviews conducted and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Administrator, Anne Buerhaus and a copy is provided.