complaint·March 20, 2026

(Continued from LIC 9099) Review of the Hospice & Facility Integrated Plan of Care shows a hospice nurse would assess and conduct case management visits once per week and a bath aide would assist with personal grooming, hygiene and bathing twice a week. Resident #1 (R1) changed hospice agencies on December 29, 2025. It was alleged that Staff did not provide an accurate dosage of medication to resident. LPA reviewed the Centrally Stored Medication and Destruction Record (CSMDR) from December 14, 2025 to January 14, 2026. R1 began taking Seroquel on December 23, 2025. Per review of text messages between Administrator (AD) and Responsible Party (RP); on December 28, 2025 AD requested to increase Seroquel dosage from 2 tablets daily to three; due to combative behavior. RP requested staff only give R1 one tablet per day. A text from December 29, 2025 between RP and AD stated NuPlazid medication would be ordered for R1 and received by January 5, 2026. Text messages from January 5, 2026 relayed NuPlazid had not been received and RP contacted pharmacy to expedite a new order to the facility. The medication was delivered to the facility and a photo was sent of the packaging. The second medication order also arrived at the facility a few days later. Interview of three of three staff denied the allegation that facility was over medicating resident. Staff gave the dosage requested by RP. One of two witnesses confirmed the allegation. One of two witnesses could not confirm, nor deny the allegation. Thus the allegation that Staff did not provide an accurate dosage of medication to resident is Unsubstantiated. Based on LPA record review, interviews and observations the allegations may have happened or are valid, but there is not a preponderance of evidence to prove the alleged violations occurred. Therefore the allegations that Staff did not provide an accurate dosage of medication to resident and Staff restrain resident in chair are Unsubstantiated. An exit interview was conducted with Lorna Smith, Administrator and a copy of this report and LIC 811 was provided to the facility. ***This is an amended report.*** (Continued from LIC 9099-C) (The text on this page has been moved to the amended LIC 9099-C) ***This is an amended report.***