Complaint Investigation Report

On 8/27/2025, Licensing Program Analyst (LPA) conducted interviews with five staff members (S1–S5). LPA attempted to interview Residents R1 and R2; however, they were not present at the facility at the time of the investigation. Interviews were successfully conducted with Residents R3, R4, and R5.

In addition to the interviews, the LPA reviewed relevant documentation, including email correspondence, assessments and re-assessments for R2, and the exit ledger following the termination of the admission agreement initiated and signed by R1.

The investigation revealed the following:

#1 Allegation: Staff are mismanaging residents’ medication.

On 8/27/2025, LPA conducted interviews with five (5) staff members (S1-S5) 5 out of 5 staff members stated that all residents receive their medications as prescribed by their physicians.

LPA attempted to interview R1 and R2 however they were not at the facility at the time of the investigation and the interviews conducted with R3, R4 and R5 stated they have received their medications as prescribed by their physicians.

#2 Allegation: Staff did not have resident re-evaluated before placement into memory care.

On August 27, 2025, Licensing Program Analyst (LPA) conducted interviews with five (5) staff members (S1–S5). During the interviews, S1-S2 staff members stated that Resident 2 (R2) had been re-evaluated on 5/16/2025 and it was determined that R2 required a higher level of care. S3,S4 and S5 could not confirm or deny that R2 was re-evaluated prior to moving to memory care.

LPA reviewed a Resident Change Form dated May 27, 2025, which documented that R2 was being transferred to the memory care unit with an effective date of May 19, 2025. The form was signed by R1 prior to R2’s relocation.

LPA attempted to interview Resident 1 (R1) and Resident 2 (R2); however, both were not present at the facility at the time of the investigation.