complaint·September 24, 2025

Allegation #1: Staff is not administering resident's medication as prescribed. The complaint alleges that staff are not following the resident’s doctor’s orders in administering the resident's medications. On September 24, 2025, between 10:30 AM and 1:30 PM, the Licensing Program Analyst (LPA) conducted interviews with the Executive Director (ED), who denied the allegation. The ED explained that the facility utilizes a medication administration system called Quick Mar, which the Medication Technicians (Med Techs) follow to ensure proper medication delivery to residents. During the same time frame, the LPA also interviewed four additional staff members #1-4, all of whom similarly denied the allegations. Additionally, a Med Tech (MT) was interviewed, and they also denied the allegations, emphasizing that they are very thorough when it comes to administering residents' medications. If the facility receives medication from the pharmacy without a doctor's orders, the medication technician (MT) will call the pharmacy to request the doctor's orders. It is crucial to have these orders, so the MT knows when the medications were prescribed and how the doctor intends for them to be administered. The MT also mentioned that they do not administer any internal medications; that responsibility falls to hospice staff or nurses. On September 24, 2025, between 10:30 AM and 1:30 PM, the LPA interviewed seven residents (R2-R8). All seven residents reported never experiencing any issues with their medications. They also stated that the MTs are very helpful regarding their medication needs. On the same date, the LPA reviewed the R1 Physician Report (covering the period from March 30, 2018, to November 17, 2022), which indicated that the resident was under hospice care. The LPA also examined the Medication Administration Records for five residents (ranging from August 1, 2025, to September 23, 2025) and found no discrepancies in any of the residents' medications. LPA could not interview R1, as R1 left the facility for a higher level of care in 2023. Unfortunately, R1 passed away in October 2024. Based on LPA Record Reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Allegation: #2: Staff inappropriately spoke to residents. The complaint alleges that the staff spoke in an inappropriate manner to the residents. On 09/24/2025, between 10:30 am 1 and 30 pm, LPA interviewed the ED, who denied the allegation and stated that the staff here would not speak to any of the residents in an inappropriate manner whatsoever. On 09/24/2025, between 10:30 am and 1:30 pm, LPA interviewed four staff (S1-S4). 4 out of 4 denied the allegation and stated that they would not speak to any of them in any way inappropriately. The LPA interviewed the Medical Technician (MT), who denied the allegations and stated that the staff would not act inappropriately. While the tone of the staff may differ from what residents are accustomed to, it is not intentional. On September 24, 2025, between 10:30 AM and 1:30 PM, the LPA interviewed seven residents (R2-R8). All seven residents denied that the staff spoke to them inappropriately. They described the staff as very nice and friendly. During the same visit, the LPA observed residents during lunchtime, where they interacted with the staff in a friendly manner, sharing laughter. Additionally, the LPA reviewed staff training records on topics such as Abuse and Neglect of Adults and the Elderly (dated October 24, 2025), Respecting Resident Rights, Promoting Dignity, and Encouraging Independence (dated October 26, 2025), Special Care Needs, including Oxygen, Ostomy, Catheter, and Skin Breakdown (dated October 26, 2023), and Understanding Dementia Care and End-of-Life Care Goals (dated September 12, 2022, and August 24, 2022). These records indicate that staff are trained in various aspects of resident care. LPA could not interview R1, as R1 left the facility for a higher level of care in 2023. Unfortunately, R1 passed away in October 2024. Based on LPA Record Reviews, observations, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. No deficiencies cited. Exit interview conducted. A copy of this report was provided to Executive Director, Brian Taube.