Complaint·November 6, 2025

The investigation revealed the following: Allegation: Staff did not notify responsible party of a resident's fall resulting in medical attention The detail of the complaint alleges that responsible party was not notified that R1 had fallen on 2/24/23. On 11/4/25, at 12:43 p.m., the Department interviewed the Executive Director (A1) who denied the allegation, stating that no fall was reported on 2/24/23. However, she confirmed that an unwitnessed fall did occur on 2/12/23, and that the responsible party was notified of the fall through an incident report. On 11/4/25, the Department obtained and reviewed an incident report concerning an unwitnessed fall that took place on 2/12/23. The report confirmed that appropriate notifications were made, including to the responsible party and the primary care physician. It further indicated that no head impact occurred, and no injuries were sustained. 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 3 Allegation: Staff failed to administer resident's medications as prescribed The detail of the complaint alleges that R1’s medication was not refilled resulting in R1 missing medication. On 11/4/25, at 12:43 p.m., the Department interviewed Executive Director Marie Hill (A1), who denied the allegation, stating that there had been no report of R1 missing any medication. A1 stated that staff members are trained in medication administration and receive regular refresher training. A1 further described the facility’s process: “The doctor sends the orders to the pharmacy, where they are reviewed before being forwarded to us. We then check and double-check the orders to ensure accuracy.” On 11/5/25, between 10:00 a.m. and 12:00 p.m., the Department interviewed 6 residents (R2–R7). R1 has not resided at the facility since 10/25/24. 6 out of 6 residents reported that they consistently receive their medication on time and have never missed a dose due to staff error . On 11/6/25, the Department obtained, reviewed and evaluated R1’s Medication Administration Record (MAR) and Physicians orders for the month of November 2022 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 3 of 3