Complaint·September 3, 2025

Based on interviews with staff, R1 wandered from their delayed-egress cottage on at least one occasion, and frequently attempted to elope after that. Charting notes regarding R1 indicate that on 6/3/25, R1 wandered "on to the streets," with staff following to supervise R1. After this and other incidents, Dial said R1's RP was "required" to acquire third-party one-on-one caregivers to supervise R1 during certain hours. This issue will be addressed in a separate case management report. In an interview, Dial said that R1 was not a good fit for the facility due to the open cottage-style layout, and R1 would be better served by a more secure facility. Dial said he did explain this to R1's RP, but he never told R1's RP that R1 needed to leave. In an interview, R1's RP did not describe R1's move-out as an eviction, and R1's RP complimented facility staff. R1's RP said that Dial did explain that R1 was "not a good fit" at this facility. R1's RP said they asked Dial what their options were, and Dial gave a preferred timeline for move-out, however this was described by R1's RP as Dial's preference, and not a requirement. In an interview, R1's RP did raise concerns regarding two of R1's medications, a certain depressant and a certain antipsychotic. LPA Moleski reviewed R1's medication list from their previous skilled nursing placement, dated 6/2/25, and a medication clarification signed by R1's physician dated 5/31/25. LPA Moleski observed on each an order for R1 to take the antipsychotic twice daily and an order for R1 to take the depressant as needed every six hours. No additional orders for either medication were included in these records. LPA Moleski reviewed R1's MARs and observed that these orders were listed as described. LPA Moleski further observed that these medications were administered as ordered during the duration of R1's stay at this facility. The department has determined the following as it relates to the allegations that a resident was illegally evicted and that medications were not provided to resident as needed: Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Dial.