Alex Falcon
Mar 2026
Our family had a loved one living at this facility for approximately three years. During that time, they were eventually diagnosed with cancer and later required end-of-life care. Unfortunately, many of the concerns I’m describing did not only occur at the end they were issues our family experienced repeatedly throughout the entire time they were there. This review reflects our family’s personal experience and observations during the time our loved one was a resident at this facility. I am sharing this so other families can be aware and make informed decisions when choosing care for their loved ones. One of the most concerning issues we experienced involved medication administration. There were multiple occasions where the medication times documented in the chart did not match what our family personally witnessed while we were present in the room. For example, one nurse told us that our family member had already been given pain medication at a specific time. However, several of us were in the room during that exact time and we know the medication was not administered then. When we questioned this discrepancy, the nurse appeared nervous and explained that their system sometimes does not allow them to enter the time earlier. However, there was no note in the chart explaining this or documenting when the medication was actually given. When we continued asking questions about the inconsistency, we were given different explanations. The responses kept changing, which made it very difficult to understand what had actually happened. The only resolution we were told afterward was that additional staff training would be provided regarding documentation. During the last weeks of our loved one’s life, this was extremely distressing for our family because proper pain management is critical in end-of-life care. Situations like this made us feel that we had to constantly monitor everything ourselves. We also found that labs and important updates were not consistently followed unless family members repeatedly asked about them. If we raised concerns or asked to speak with someone in charge, we were often told someone would call us back, but those calls rarely happened. We frequently had to follow up ourselves and push for answers. Another deeply troubling situation was brought to our family’s attention by the facility itself. One day, we received a call from the facility informing us that a staff member had yelled at our loved one and called them “crazy.” Our loved one had a brain tumor and was confused at times, and this interaction reportedly occurred during the night shift. We were told the situation came to light because the roommate had witnessed the incident and was speaking about it. Learning that a vulnerable patient may have been spoken to this way during end-of-life care was incredibly upsetting for our family. Afterward, we became close with other residents and family members at the facility, and we later heard that the same nurse had returned to working there, which was very concerning to us. Based on our experience, families should be very proactive and present if their loved one is at this facility. Advocacy from family members seemed to be the only way we were able to get attention to important concerns. We also recommend that families document concerns, keep records of communication, and follow up consistently when something does not seem right. Our family hopes that by sharing this experience, the facility takes these concerns seriously and works to improve the level of care and accountability provided to vulnerable residents. Families researching a nursing home or skilled nursing home for their loved ones should carefully review all feedback and remain actively involved in their family member’s care.
