complaint·December 4, 2025

Pg.2 Resident is not accorded rights to refuse medications. On the allegation that the Resident is not accorded rights to refuse medications; the RP’s concern is that the Resident (R1 refuses to take their medication because R1 does not like how it makes them feel. Furthermore, it is alleged that the medication technicians force R1 to take their medications. However, the RP is unsure whether the staff are physically forcing R1 to take the medication or simply verbally pressuring R1 to comply. To investigate the allegation, LPA Urena conducted record review and interviewed the Administrator, staff, and R1’s assigned Social Worker (SW) with the Veterans’ Administration. R1 was not available for an interview. The record review revealed that R1 has been receiving the prescribed medication as directed by the doctor. No refusal of medication has been recorded. The interview with the Administrator revealed that R1 has been complying with taking their medication. The staff’s interview revealed that R1 has been compliant with the medication. The interview with R1’s SW revealed that R1 has not shared at any time that staff have forced them either physically or verbally pressured them into taking their medication and are aware that R1 is taking their medication as prescribed. Based on the information obtained through record review and interviews, the staff has not violated the R1’s personal rights based on R1’s intake of the medication. Therefore, the allegation is deemed Unsubstantiated at this time. Continues on LIC 9099C...page 3. Pg. 3 Staff do not ensure residents health care needs are being met. On the allegation that Staff do not ensure residents health care needs are being met; the RP’s concern is that the staff are not capable of providing the level of care R1 requires and have resorted to placing R1 in involuntary restraining holds, to stop the behavior displayed by R1. To investigate the allegation, the LPA conducted record review and interviews. Record review of the Incident Reports (LIC 624) sent to the Community Care Licensing (CCL) Office, revealed that the Administrator has followed protocol and regulations by informing the CCL of any incidents involving R1. Record review revealed that R1 has been residing at the facility for about 1.5 years, and during this time R1 has been placed on one involuntary restraining hold. The interview with R1’s SW from the Veteran’s Administration Department (VA) revealed that the facility’s staff proactively communicates with the VA doctors about any changes in R1’s behavior, allowing for VA’s intervention for a positive outcome when R1 becomes combative. Per the SW, there has been one (1) incident of involuntary restraining hold and one (1) voluntary occurrence which occurred on 11/19/2025 when R1 displayed aggressive behavior towards facility staff. The facility Administrator called the VA’s office and the VA’s SW and field support staff arrived at the facility to speak with R1. R1 was advised by the VA staff that R1 needed to be seen by a VA doctor, to which R1 agreed and R1 was transported by car by the VA staff to the VA’s doctor’s office. Based on information obtained through record review and interviews, facility staff are following regulations and protocol to provide the level of care needed to R1, at this time. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted with the facility’s designated staff. A copy of the report was issued.