complaint·May 15, 2025

Regarding the allegation: Staff did not administer medication to a resident in care. On 05/14/2025, the Department received a complaint alleging staff not administering Resident #1’s (R1’s) morphine medication as prescribed. During today’s visit, the LPA reviewed R1’s records including but not limited to hospice documents, controlled drug record, and resident appraisal. R1 was admitted to hospice on 04/24/2025 with terminal diagnosis of Alzheimer’s disease. On 04/25/2025, R1 was prescribed through hospice Morphine Sulfate 20 mg/1mL Solution (0.25 ml dosage) for once a day. On 05/07/2025, R1 received a new physician order for Morphine Sulfate 20 mg/1mL Solution (0.25 ml dosage) to be given every six (6) hours. On 05/08/2025, R1 again received a new physician order for Morphine Sulfate 20 mg/1mL Solution (0.25 ml dosage) to be given every two (2) hours. Interview and record review revealed that R1’s Morphine Sulfate 20 mg/1 mL solution was in pre-filled syringes that were centrally stored. On 05/08/2025, per controlled drug record, R1 was last given Morphine Sulfate 20 mg/1mL Solution at 8:30 p.m. and staff did not again offer R1 the medication until the following morning, 05/09/2025 at 6 a.m. R1 was not given four (4) scheduled doses and staff did not properly assist R1 with self-administration of medication as prescribed. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff did not administer medication to a resident in care” is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D). Civil Penalty issued for the amount of $250. Exit interview conducted. A copy of the report and appeal rights were provided.