The complaint alleged that staff sometimes bring R1's medication in the morning, while at other times R1 has to seek out staff to receive their medication. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegation, stating that the Medication Technicians (Med Tech) follow the doctor's orders and ensure that all medications are given to R1 on time.

On the same date, the department also interviewed two Medical Technicians (MT1 and MT2), who denied the allegation and explained that while they follow doctor’s orders, they do not assist R1 with medications, as R1 has been managing their own medications. They also mentioned that if the facility receives medications without a doctor’s order, they contact the doctor’s office to request that the orders be faxed. They emphasized that medication must be administered 1 hour before or after the scheduled time. Additionally, they stated that they use the Electronic Medication Administration Record (E-MAR) system to assist with residents' medications and to prevent errors.

Moreover, the department interviewed five staff members (S1-S5), all of whom denied the allegations and confirmed that only Med Tech assist with administering medications. The department also spoke with seven residents (R1-R7); six of them denied the allegations and reported that staff helps them with their medications without any issues. Resident R1 stated that they do not require assistance with their medications and can manage them independently. On April 28, 2026, the department reviewed R1's records, including the Medication Administration Record from July 8, 2024, to August 19, 2024, and found no discrepancies

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.

The complaint alleged that staff were not allowing Resident #1 (R1) to manage their own medications, despite the doctor’s approval. On April 28, 2026, the department interviewed the Administrator (A1), who denied the allegation. A1 stated that the medication technicians follow the doctor's orders and ensure that all resident medications are delivered on time.

A1 also explained that when a resident is admitted to the facility, a medication self-management assessment is conducted to determine whether the resident is capable of self-medicating. When R1 was admitted to the facility on July 19, 2024, R1 expressed a desire to self manage their medications; however, R1's physician report dated 07/11/2024 indicated that R1 needs assistance with medications. After a month of admission, the facility performed a medication self-management assessment on September 9, 2024, which indicated that R1 was capable of storing and managing their medications. Since that assessment, the facility has not been involved in storing or managing R1's medications. Also, R1 refused to provide the facility with the doctor's notes or after a visit to a physician.

On April 28, 2026, the department also interviewed two Medical Technicians (MT1 and MT2), who denied the allegation. They stated that they follow the doctor's orders and that the facility does not charge a fee for managing residents' medications under the Assisted Living Waiver (ALW), since R1 is in the ALW program. They further explained that the facility requires a pharmacy profile for residents and, if everything is in order, approves the self-management of medications.

Report continued on LIC9099C

On July 3, 2026, the department interviewed the Resident Services Director (RSD). The RSD stated that after admission, the facility needed to ensure that resident R1 was capable of managing their own medications. To evaluate R1's ability to administer their own medications, the facility conducted an Assessment for Medication Self-Management on September 9, 2024. Since R1's self-management was approved, the facility stopped providing assistance with or managing R1’s medications.

Additionally, the department interviewed R1's doctor, who confirmed during R1's final visit on August 19, 2024, that R1 was indeed capable of managing their own medication regimen. However, on April 28, 2026, the facility indicated that they had not received any physician reports regarding R1. The department later reviewed a physician report dated July 11, 2024, which stated that R1 needed assistance with medications.

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 Lifestyle Director Kelli Grissom.