complaint·December 9, 2025

Four of Eight Staff members who are Medication certified stated that they review Resident care chart and place medications inside small container cups and hand over cups to residents in hand. Certified staff stated that they watch Residents take medications from cup and visually confirm the medications have been taken by resident. Certified staff state that they log in residents Medication Administration Record (MAR) whether or not medications were taken. Eight of Eight staff interviewed all stated that they do not force Residents to open their mouths to confirm medications are swallowed. Seven Residents were interviewed and the following was mentioned, regarding staff ensuring residents take medications as prescribed. Five of seven residents stated that the require assistance with medications and state that staff either go to resident apartment or dining area to assist with meds. Five of five residents stated that Staff hand over meds and waits till residents take medications before leaving. Three of five residents that require assistance with meds stated that staff inform resident of medication given before handing over. Two of five residents stated they are not made aware of what medications are given. Department reviewed R1’s Medication Administration Record from January 2024 to November 2025 and Review of R1’s record shows that R1 was being assisted with medications and beginning on September 12, 2025 records show R1 began to refuse medications frequently. R1’s Physician’s report dated 11/4/2022 has a diagnosis of Traumatic Brain Injury (TBI) and states under medication management that not able to administer prescription meds. Resident 1’s appraisal dated November 2, 2022 states resident needs help with medication, and notes "administered to them and observe resident taking medications, do not leave with resident". Based on conflicting information provided in investigation, the allegation staff did not ensure resident took medication as prescribed has not met the preponderance of evidence, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED. Regarding allegation Staff retaliated against resident for exercising their rights was investigated and the following information was provided: Eight of eight staff members interviewed stated they have never retaliated against a resident for exercising their rights. Eight of eight staff stated they have never witnessed other team members retaliate against a resident and all staff interviewed stated that they respect the personal rights of residents in care. Interviews with seven residents revealed that five of seven residents stated they have not had any issues with staff members and feel that staff respect residents personal rights. Two of seven residents stated that they have had issues with staff members respecting their personal rights and claim staff need to be properly trained on resident rights. Based on information provided, the preponderance of evidence has not been met, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Sarah Devore and copy of reports were provided.