Complaint·November 14, 2025

Allegation: Staff member yelled at hospice worker in the presence of residents in care. Record review of Hospice Record Incident Report (10/01/25 14:03) revealed Staff #1 became verbally aggressive (yelling) and physically came (within 2 feet) towards hospice worker to the point where another caregiver had to pull S1 away from the hospice worker. Hospice worker reported the incident occurred in front of other residents in the home. Record review of video recording revealed S1 and Hospice Staff having a disagreement over a resident’s medication and pain level. S1 also indicated that S1 can prevent the Hospice Staff from returning to the facility. From the beginning to the end of the discussion, S1 and the hospice staff maintained a personal conversational distance. The discussion occurred in front of the common bathroom and R1’s room (45 seconds) and in the entryway hallways (60 seconds). Two alert residents were in the living room for about one minute during the disagreement. The living room is about eleven feet from the common bathroom and about sixteen feet from the entryway. S1 indicated that S1’s voice is naturally loud and the hospice staff walked off while S1 was still talking. Staff #2 indicated that S1 and the Hospice Staff had an argument because of the pill box. The Administrator indicated that S1 started to question the Hospice Staff and Staff snapped back at S1. S1 wasn't screaming at the Hospice Staff. R1’s Responsible Party/Witness 1 indicated R1 was treated great at the facility. Two out of two responsible parties/witnesses (W2 – W3) indicated staff is professional and wonderful. Regarding the allegation, “Staff member yelled at hospice worker in the presence of residents in care,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff do not ensure that resident is administered their medication as prescribed by their physician. Regarding the allegation, “Staff do not ensure that resident is administered their medication as prescribed by their physician,” it is being alleged that three days of Norco medication was still in stock on 09/22/25. Review of Medication Administration Record (September) revealed Norco was refused on 09/13/25 – 09/14/25 (AM, Noon, and PM) and 09/29/25 – 09/30/25 (PM). Review of Hospice Record Visit Note Addendum (signed 10/09/25) revealed R1 had three days’ worth of medication. Continue to LIC9099-C. R1 should have ran out on 09/19/25. The present caregivers contacted Staff #4 and S4 indicated that R1 had not missed medication. Record review of Hospice Record Incident Report (10/01/25 14:03 ) revealed S1 indicated if R1 cannot take medication then S1 will not administer it. Hospice informed S1 to let Hospice know when patient is unable to take medications. S1 indicated that R1 refuses medication or is asleep. S1 indicated that hospice is not called since they come to the facility twice per week, check the medication bottle, and review the medication administration record. S1 indicated that the nurse is informed then. Staff #2 indicated that R1 refuses medication and is sleep during lunch. Staff #3 indicated that R1 refuses medication and sometimes sleep the full day. Staff #4 indicated that R1 is typically asleep, and some medication is missed. Administrator indicated that R1 refuses medication, or it is given when R1 wakes up late. The nurse is notified when she comes in. R1’s Responsible Party/W1 indicated that medication was not administered because R1 would sleep for a day and a half and not eat, refuse medication, and get angry, yell at people, and tell them to get out of the room. W1 indicated R1 has refused medication from W1 in the past. Interview with Hospice Representative/Witness 6 indicated if a resident missed medication for a day then they will document it and report it to whoever follows up that week. If it is ongoing then they should report it to hospice agency. W6 indicated that facilities should wake residents up for routine medication. Two out of two responsible parties/witnesses (W2 – W3) indicated they do not have medication complaints. Resident #2 indicated R2 does not have medication complaints. Regarding the allegation, “Staff do not ensure that resident is administered their medication as prescribed by their physician” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to Caregiver Marjorie Ravao.