complaint·April 29, 2026

Interview with S2 stated R1 would pocket or spit out food, but at times R1 would still take their medication. S3 interview stated R1 began refusing or pocketing food approximately one week prior to transitioning towards end of life. S4 stated that although R1 was sometimes not eating, the medication was small enough to be crushed and given in a spoonful, though at times R1 would drool it out. LPA reviewed R1’s medication records and physician orders. Facility documentation reflected a mechanical soft diet with thin liquids and an order for crushed medications, while hospice records reflected a physician order for a puree diet. Due to limited staff notes, LPA was unable to verify all dates of medication administration. Based on record review and interviews, the allegations that staff mismanaged medications is Unsubstantiated. Unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted were this report was discussed and a copy provided to Administrator, Melissa Buckridge