complaint·March 14, 2025

The investigation revealed the following. Regarding Allegation(s) : Staff neglect resulted in a resident's death – It is alleged facility staff neglected R1 which resulted in R1’s death. Review of R1’s resident records revealed R1 was admitted into the facility on 06/21/2023 and was self-responsible. R1 was transferred from another hospice care provider on 11/04/2024 and new hospice care orders were placed. On 11/05/2024, during hospice care visit, hospice care staff documented R1 requested that medication ordered on 11/04/2024, not be ordered and administered unless “absolutely necessary”. On 11/05/2024, R1’s physician ordered R1 discontinue the use of Morphine Sulfate 10mg/0.5 ml- every 4 hours as needed, Lorazepam 1mg/0.5m- every 6 hours as needed, Morphine Sulfate 20mg/1ml- every 4 hours as needed, Morphine Sulfate 5mg/0.25ml- every 4 hours as needed, Lorazepam 1 tab- every 4 hours as needed. Review of R1’s hospice care notes and facility care notes revealed hospice staff and facility staff regularly documented R1’s care and supervision. Review of R1’s death certificate did not corroborate above allegation. Four (4) out of the four (4) staff interviewed denied above allegation. Four (4) out of the four (4) residents interviewed denied above allegation. R1 was not available for interview. Interview with R1’s family did not corroborate this allegation. 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, therefore the allegation is UNSUBSTANTIATED . Staff had unauthorized access to a resident's personal funds- It is alleged facility staff were monitoring R1’s financial situation. Review of R1’s resident records revealed R1 was admitted into the facility on 06/21/2023 and was self-responsible. Four (4) out of the four (4) staff interviewed denied above allegation. Four (4) out of the four (4) residents interviewed denied above allegation. Interview with R1’s family did not corroborate this allegation. Review of R1’s facility record, including payments made to the facility for services, did not corroborate above allegation. 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, therefore the allegation is UNSUBSTANTIATED . No deficiencies were cited during this complaint investigation visit. Exit interview was conducted. A copy of this report was provided via email.