complaint·February 24, 2026

Hospice notes described R1 as medically fragile with ongoing pain, shortness of breath, increased anxiety, and agitation. Charting notes from January through April 2025 showed R1 regularly received morphine and Ativan as ordered, while staff documented that R1 often expressed severe pain shortly after receiving their PRN medication. R1 frequently stated that they believed staff were withholding their medication, even when charting showed the medication had just been administered. Staff consistently documented attempts to redirect R1, explain hospice medication orders, and reassure them about their care. Review of R1’s MARs showed that R1 was out of the facility for extended periods: from January 31, 2025 through March 22, 2025; again from March 23, 2025 through April 3, 2025; and again from April 6, 2025 through April 30, 2025. MARs and charting showed that on the limited days R1 was present in the facility, they received their medications as ordered. Facility records described several incidents where R1 became distressed, attempted to use their wheelchair as a walker, refused redirection, grabbed staff clothing, and verbally escalated to the point that 911 was contacted. R1 also called 911 independently, attempting to reach hospice and request changes to their medication orders. Incident reports and hospice notes both indicated that R1 frequently reported feeling unheard or unsupported, though documentation showed medications were given as prescribed. For R2, LPA reviewed MARs dated August through September 2025, physician orders, and charting notes from January through September 2025. R2 had COPD and acute kidney failure and was prescribed one medication daily at noon. MARs showed that the noon medication was withheld from August 1 through September 10, 2025 following orders from a physician or registered nurse. Staff had initialed and documented each date accordingly. Charting notes indicated that R2 sometimes became upset, thinking their medication was late when it was not, and also showed confusion about how many times per day they should receive medication. Staff documented multiple instances where R2 forgot that they had already taken their medication. No evidence was found indicating staff failed to administer medication as ordered. Record review, interviews, MARs, and hospice documentation did not support the allegation that staff failed to administer medications to R1 or R2. The documentation consistently showed that both residents received medication in accordance with physician and hospice directives. R1’s concerns appeared related to ongoing pain, anxiety, and behavioral symptoms, while R2’s concerns were related to confusion about medication schedules. The allegation that staff did not administer medications as prescribed is unsubstantiated. This means there is not enough evidence to prove the allegation occurred. An exit interview was conducted with Diana Weinstein A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Diana Weinstein whose signature below verifies receipt of these rights.