Complaint Investigation Report
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
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction