complaint·March 27, 2026

Review of R1’s medical assessment dated August 13, 2024, revealed that R1 was unable to administer their own prescription medications, unable to administer their own PRN medications, and unable to store their own medications. Review of R1’s Medication Administration Record (MAR) for March 19, 2026, revealed that R1 refused two morning medications. Furthermore, review of the MAR did not reveal that R1 received their medications late following the incident. Interviews with staff and residents provided conflicting statements as to the reasoning of R1 not taking two of their medications. Interviews with staff did not reveal that staff leave medications in residents’ bedrooms nor do staff give medications late. Based on interviews and record review, the investigation did not yield a preponderance of evidence to conclude staff mismanaged resident's medication. Based on the foregoing, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Karen Roper and Assistant Executive Director Theresa Gamez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.