Complaint·April 24, 2026

Assigned staff were on duty and observed to be meeting the needs of residents in care. Interviews conducted did not reveal any corroborated statements of facility kept unclean or unsanitary. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation: Staff is providing resident unauthorized medication. LPA conducted interviews and record reviews as noted above. Based on review of care notes pertaining to resident1 (R1), it was revealed that medication Hydroxyzine HCL 25mg was given to R1 per physician’s orders which state: “Take 1 tab by mouth every 6 hours as needed for agitation.” Additionally, a review of facility care notes revealed communication between facility staff and responsible person for R1 regarding the use of the above medication which included a request by responsible person on 1-11-2026 to provide this medication due to R1 experiencing an agitated episode. Interviews conducted also confirm the above. As a result, there is not a preponderance of evidence to conclude staff has provided unauthorized medication to a resident. As a result, this allegation is UNSUBSTANTIATED. Allegation: Staff did not keep resident’s authorized person informed regarding resident’s care. LPA conducted interviews and record reviews as noted above. Based on review of care notes and email communications, it was revealed that various communications between staff and responsible party for R1 took place during January 2026 which included medication use and contents of R1’s care plan. Specifically, on 1-20-2026, care notes revealed that a care conference was conducted between facility staff and R1’s responsible persons which resulted in an adjustment to R1’s care plan and the addition of hands-on services. A review of email communication dated 1-21-2026 revealed a follow up email to R1’s responsible person to confirm the additional services to be added to R1’s care plan. The email also stated that no additional costs are to be imposed for this change at that time. Interviews conducted also confirm the above. As a result, there is not a preponderance of evidence to conclude that staff has not kept resident’s authorized person informed regarding resident’s care, therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director, and a copy of this report was provided. Appeal rights provided.