Complaint·December 13, 2025

Regarding the allegation: Medication mismanagement contributed to residents death. It is being alleged that staff members S2 and S5 are purposely providing false information to hospice pertaining to residents’ medication which resulted in the death of two (2) residents (R1-R2). To investigate the allegation, LPA conducted record review of both R1’s and R2’s files. Record review revealed that R1 was admitted to Gentle Touch Hospice on 9/26/2023 due to a decline in their condition as a result of their medical diagnosis. On 9/02/2025, LPA requested R1’s medical records from hospice. Record review revealed that R1 was placed on various medications due to their diagnosis. The medication in question (per the Reporting Party) was allegedly discontinued by S5 which caused R1’s death on 4/17/2024. However, LPA’s record review of R1’s Interdisciplinary Group Review (IDG) showcased that R1’s attending physician had placed the order to discontinue said medication on 4/14/2024. The order to discontinue the medication was documented to be due to R1 being, “…susceptible to bruising while on anticoagulant” (page 2). Additional record review confirmed R1 was observed during hospice visits to have had a change of condition resulting in their Plan of Care being updated to meet R1’s needs until their time of death. LPA’s review of R1’s Certificate of Death documented their death to have been contributed by both cardiac arrest and cognitive decline. LPA’s record review of R2’s file revealed that R2 was admitted to Easy Care Hospice on 9/13/2024 due to a decline in their condition related to their medical diagnosis. On 9/02/2025, LPA requested R2’s medical file from Hospice. Record review revealed that R2 was placed on various medications due to their diagnosis. The medication in question (per the Reporting Party) was allegedly requested to be discontinued by S5 which caused R2’s death on 7/17/2025. However, LPA’s record review showcased that R2 had been sent to the hospital on 9/06/2024, where an order to discontinue the medication in question was placed by the attending physician on 9/11/2024. Additional record review of R2’s Physician’s Orders (6/02/2025 to 7/15/2025) showed no record of said medication listed. LPA’s record review of R2’s Certificate of Death documented their death to have been contributed to both cardiac arrest and cognitive decline. It was also alleged staff are receiving compensation for hospice enrollment. LPA’s interview with S2 regarding whether they are receiving any compensation through monetary gains for residents being admitted into Hospice were denied. LPA’s interview with S1 revealed that they would “fire” any staff that would partake in any financial gain through residents being admitted into hospice. LPA attempted to interview S5 but S5 no longer works at the facility and could not be contacted. Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Staff are not dispensing medication as prescribed. It is being alleged that staff are not administrating medication as prescribed. To investigate the allegation LPA conducted interviews with four (4) staff members. All four (4) staff members confirmed that resident’s medications are administered as prescribed. During LPA’s physical plant tour, LPA observed the medication rooms located in both the Assisted Living Unit and the Memory Care Unit. LPA observed, at random, a total of ten (10) residents’ medications. LPA observed all ten (10) residents' medications to be labeled correctly, assigned to the correct person and administered on the correct date. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to The Regional Director of Operations .