complaint·March 29, 2025

The investigation revealed the following. Regarding Allegation: Staff did not administer resident's medication as prescribed – It is alleged on 01/10/2023, R1’s medications were discontinued by the facility physician. Five (5) out of the five (5) staff interviewed denied this allegation. Seven (7) out of the eight (8) residents interviewed denied this allegation. LPA Ramirez attempted to contact R1 for an interview, but R1 was not available for an interview. LPA Ramirez reviewed R1’s facility file and it revealed R1 was admitted into the facility in August of 2021. Review of R1 Physician’s report dated 01/05/2023, revealed R1’s physician documented R1 was non-compliant with medication recommendations. Review of R1’s Physician’s report dated 02/21/2023, revealed R1’s physician noted R1 was “Resistant to medication management and wants to choose what medications to take and never accepts medical advice.” LPA Ramirez reviewed a prescription medication change order by R1’s physician dated 01/06/2023. On 1/6/2023, R1’s physician ordered R1 discontinued twelve (12) medications and ordered R1 be administered four (4) new medications. Staff interviewed revealed medication technician's administer and or discontinue medications according to the physician's order. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No violations were cited for this investigation. Exit interview was conducted. A copy of this report was provided via email.