complaint·April 23, 2026

Allegation #1: Staff did not seek timely medical care for residents . The complaint alleged that residents experienced blood in their urine for three days without staff seeking medical care or contacting hospice. On April 22, 2026, the department interviewed the Administrator (A1), who stated that staff would call Med Techs (MT1-MT2) or the Emergency Medical Service (EMS) to assist residents who needed care. The department also interviewed two Med Techs (MT1-MT2), who denied the allegation and asserted that when a resident faces a medical emergency, they would go to the resident's room to assist, even if the resident is in hospice. MT1 stated that it is common for residents to have blood in their urine after changing the catheter. If, after three days, they find that the bleeding continues, they will call and notify the hospice nurse. They mentioned that if hospice nurses were not nearby, they would call Emergency Medical Service (EMS) for help or send the residents to the hospital. Additionally, the department interviewed two staff members (S1 and S2), both of whom denied the allegation. They stated that when a resident presses the call button, it takes 2 to 3 minutes to reach the resident's room and provide assistance. On the same day, the department interviewed six residents (R3-R8), all of whom denied the allegations and stated that staff help them with their medical needs. The department also reviewed hospice notes from March 2024 to July 2024, which were signed in and out, showing that hospice nurses visited residents R1 and R2 every other day. The department was unable to interview R1 because R1 passed away in July 2024. The department was also unable to interview R2 because R2 passed away in November 2025. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore, the allegation is Unsubstantiated. Allegation #2: Licensee did not ensure resident’s medication was administered by an appropriately skilled professional. The complaint alleged that the licensee did not ensure resident's medication was administered by an appropriately skilled professional. On April 22, 2026, the department interviewed the Administrator (A1), who denied the allegation and stated that Med Techs assisted the residents with their medications. On the same date, the department also interviewed two Medical Technicians (MT1 and MT2). They stated that only Medical Technicians and Nurses are responsible for administering medications to residents, and that caregivers are not trained to assist residents with their medications. MT1 and MT2 emphasized that they would never administer medication to a resident without a doctor's orders. They also indicated that if medication arrived without a doctor's order, they would contact the doctor and the pharmacy to obtain those orders. Additionally, the department interviewed two staff members (S1 and S2), both of whom denied assisting residents with medications. S2 stated that if medication was found in a resident's room, they would notify the Medical Technicians because family members sometimes bring medication for residents without the facility's knowledge. The department interviewed six residents (R3-R8), all of whom reported that staff assisted with their medications without any issues. The department also reviewed medical records, including Physician Reports dated January 30, 2023, and July 2, 2024, which indicated that both R1 and R2 required the facility to store and assist with their medications. The department examined the completion certificates for the Relias Med Tech training courses for MT1 and MT2. Unfortunately, the department could not interview R1, because R1 passed away in July 2024, and also R2, who passed away in November 2025. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator Bassem El-Rabaa.