complaint·January 28, 2026

On July 3, 2025, the new physician’s orders for morphine sulfate 20 mg/mL, 5 mg every 4 hours as needed (PRN). The order was faxed to the facility on July 4, 2025. Facility documentation indicates that medication was administered in accordance with hospice instructions beginning on July 4, 2025. The June 22, 2025, discharge notes indicated R1’s diet consisted of a combination of regular and modified texture diet with 1:1 supervision and no straws. The after-visit summary dated June 24, 2025, showed medication changes including acetaminophen, amoxicillin, sennosides-docusate sodium, sodium chloride, and spironolactone, while several medications were discontinued, including vitamin D3, meloxicam, quetiapine, and spironolactone (replaced by similar medicines). RP stated that a refund was received on July 23, 2025, and denied saying that the facility failed to adhere to the admission agreement. RP alleged that morphine was not given as prescribed and stated the last dose was administered at 9:30 p.m. the previous night, with instructions for administration every 4 hours as needed. RP also reported that R1 was not supposed to receive food, but staff gave oatmeal. RP stated that when visiting, they did not observe food in R1’s mouth or witness feeding. RP indicated they typically visited the facility daily at 5:30 p.m., except for a few missed days, and were unaware of R1’s specific diet plan or morphine administration schedule. RP provided the name of an additional hospice nurse who was present during the days before R1’s passing on July 8, 2025. Outside Source 1 (OS1) reported being a covering hospice nurse and not the regular case manager. OS1 visited R1 on July 4 and July 5, 2025, and administered morphine at 9:36 a.m. on both days. OS1 stated that they did not observe mistreatment or neglect by staff and confirmed that their involvement was limited to coverage during the specified dates. No response or returned call from case-carrying hospice nurse. On October 9, 2025, LPA spoke with the OS2 who could not recall the case regarding the administration of morphine to the resident. LPA asked OS2 about a handwritten schedule for administering morphine. OS2 stated that the handwritten schedule was probably written by the resident’s family member. Staff 1 (S1) reported working two days per week and stated that R1 was provided soft foods such as oatmeal for breakfast and pureed foods for lunch and dinner. S1 noted that when R1 declined food, R1 turned their head away. S1 denied administering morphine and stated that they waited for a physician’s order prior to administration. S2 stated that R1 received oatmeal for breakfast and pureed food for other meals. S2 confirmed R1 was declining and eating less. S2 denied administering morphine and confirmed that only regular medications were provided. S3 stated that R1’s family requested morphine to be administered, but S3 explained that he could not do so without a physician’s order. The family contacted the police, and S3 explained to responding officers that morphine could not be administered without proper authorization. The physician’s order for morphine was prescribed on July 3, 2025. S3 also reported that the family requested S3 to sign documents related to long-term care benefits, which S3 declined as the facility is not a skilled nursing facility. A refund was issued and cashed on July 23, 2025. S3 confirmed R1 received oatmeal for breakfast and pureed food for other meals. Based on the information obtained through interviews, record review, and hospice documentation, there is insufficient evidence to support the allegation that the facility failed to administer morphine as prescribed or provide food contrary to dietary orders. Records and hospice documentation support that morphine was administered as ordered beginning July 4, 2025. Additionally, dietary notes confirm that soft and pureed foods were consistent with R1’s prescribed diet. The allegation regarding non-adherence to the admission agreement was not supported, as the RP denied making such a statement, and documentation supports that the refund was processed and received by the family on July 23, 2025. Therefore, the allegations are determined to be: UNSUBSTANTIATED – Meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred. An exit interview was conducted with the Caregiver. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Caregiver, and his signature on this report confirms receipt of the Licensee Rights.