Staff did not follow the orders of a licensed physician.

Based on the information provided, the investigation conducted by the department involved facility observations, record review, and interviews with staff and residents to investigate the complaint allegation. During these interviews with three (3) staff and three (3) residents, it was revealed that the facility dispensed all residents' medications on time and administered them as scheduled. Residents’ interviews indicated that staff were assisting them with their medications without any issues. Furthermore, a review of the records for the month of October 2025, indicated that the facility maintained proper logs for all medications in the centrally stored medication log, following physician's orders, and documenting them in the Medication Administration Record (MAR) without any errors. Staff interviews reflected that residents were given medications on time per their physician’s orders and there were no problems to address. R1’s hospice agency staff’s interviews indicated that there were no concerns regarding facility staff’s care or medications management related to R1. Based on these findings, this allegation is considered UNFOUNDED.

Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.