Complaint·November 5, 2025

The investigation revealed the following: Allegation: Resident was admitted without consent of responsible person The detail of the complaint alleges that the resident nor his conservator sign the admission agreement. On November 4, 2025, at 12:43pm the Department interviewed Executive Director Marie Hill (A1) who denied the allegation stating the responsible party did sign the admission agreement. A1 further stated that the Residents do not sign because the facility is full memory care and they need their responsible party to sign. On November 4, 2025, between 1:00pm and 2:30pm, the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed 5 out of 5 could not provide any input on this allegation because they are not part of the residents' admission agreement signing process. On November 4, 2025, the Department obtained and reviewed a copy of the R1’s admission agreement which revealed that the document was signed by the responsible party and the Executive Director. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED. Page 2 of 4 Allegation: Staff do not distribute medications according to physician’s orders. The detail of the complaint alleges that the staff doesn’t give R1 his medication on time. On November 4, 2025, at 12:43pm, the Department interviewed Marie Hill (A1) who denied the allegation stating that there has been no report of R1 missing medication. A1 further stated that her staff are trained on medication administration and have frequent refreshers. A1 states that “the facility get the orders from the doctor, it's sent to the pharmacy first and they check orders before it is sent to us. Then we check and double check the order to make sure it is correct.” On November 4, 2025, between 1:00pm and 2:30pm, the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed 5 out of 5 denied allegation stating that R1’s medication was given on time and as directed by the doctor. 5 out of 5 staff state that they have had medication training. Lastly, 5 out of 5 state that missed medication is rare, but when it happens they report it to the doctor, the responsible party and to the Department via incident report. On November 5, 2025, between 10:00am and 12:00pm the Department interviewed 6 residents (R2-R7). R1 was not interviewed as R1 no longer lives at the facility as of 10/25/24. Of those interviewed 6 out of 6 stated that they receive their medication on time and they have never missed a dose due to staff not giving it. page 3 of 4 On November 4, 2025, the Department obtained, reviewed and evaluated R1’s Medication Administration Record (MAR) for the months of August-September 2023 and found no discrepancies during the review period. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED. There were no deficiencies cited during today's visit. Exit interview conducted and copy of report provided. Page 4 of 4