Complaint·May 19, 2026

Staff reported that due to the G-tube, they attempted to have R1 evaluated at the hospital to ensure proper care. R1 was later transferred to a skilled nursing facility for a higher level of care. Staff stated that R1 gathered their belongings and left the facility on their own. Staff also reported that R1 was informed they could return to the facility once the G-tube was no longer in place. Witnesses reported that R1 appeared distressed and felt they had limited time to leave. However, witnesses also confirmed that staff did not state that R1 was being evicted. Records reviewed show that R1 signed an Admission Agreement which explains that certain medical conditions, including the need for G-tube care, may require reassessment and possible termination of services. Regarding the allegation that staff withheld medication, staff reported that R1 was provided prescribed pain medication prior to returning to the facility with the G-tube. Facility records confirmed that medication was administered according to physician’s orders on the morning of January 26, 2026. Staff stated that after R1 returned with the G-tube, they did not administer medication because there were no doctor’s orders or instructions on how to safely provide medication with the newly placed device. Staff reported that this decision was made to ensure resident safety. While one witness stated that R1 was denied pain medication, this information was not supported by records reviewed. Staff consistently reported that medications are provided when there are proper physician orders in place. Based on interviews and records reviewed, there is insufficient evidence to support that the facility conducted an unlawful eviction and that staff withheld medication. Therefore, the allegations mentioned above has been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report and list of confidential names were provided to the facility.