complaint·July 29, 2025

medication of ABHR, and Seroquel, but R1 never received a physician’s order for Ativan. Record review revealed that prescription for ABHR gel went from a PRN medication to a routine medication. Prescription for Seroquel went from bedtime to twice a day. Comfort hospice records show that updated physicians’ orders were received on July 4, 7th and 23, 2025 for ABHR and Seroquel only and there was no Ativan registered to the order. MAR sheets for July for R1 reflect that all medication prescribed to R1 has been administered and no discrepancies were observed in the logs. It is alleged that facility staff are not allowing doctors orders. Interviews with 2 of 2 staff stated that R1 had been having more episodes of agitation than usual. Staff reached out to hospice to have prescription of agitation to be changed from PRN to routine medication while primary doctor was on vacation. Staff stated that it was the only medication that was requested to be modified. Record review revealed that hospice documentation from Comfort Hospice visiting professional dated July 7, 2025, reflects that they received a request for ABHR to be made to a routine medication. The physicians order received from Comfort Hospice Inc. on July 7, 2025, stated ABHR gel to be applied four times daily routine and was no longer a PRN medication. Physicians’ orders for July 4th and 23rd, 2025 reflect update to medication dosage and MAR sheets for July reflect the changes to medication and given as prescribed. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.