complaint·May 10, 2025

On 05/10/2025, from approximately 12:30pm -3pm LPA Chochian conducted additional interviews with three staff and reviewed former resident’s (R1) records including but not limited to medication and hospice records. At approximately 3pm, LPA toured the facility and conducted interview with randomly selected residents; LPA continued the tour with HCD and interviewed additional residents. Total eight (8) residents were interviewed. Also, during the tour at approximately 4pm, LPA toured the medication room and medication dispensing and recording procedures were reviewed with HCD. Following is a summary of the allegations and investigation finding: Allegations “Staff is chemically restraining the resident and Staff are administering the resident medication without a doctor’s prescription”. It was reported that resident #1 (R1) is being chemically restrained by the staff at the facility for financial gain. Additionally, it was reported, that on 11/17/2024 R1 was prescribed Lorazepam 3mg, and the physician was unaware of this medication change. A review of R1’s centrally stored medication record and medication administration records conducted revealed no discrepancies. Records review revealed R1 was on hospice and the prescription for Lorazepam was 0.5mg which was prescribed by the hospice physician. Staff interviewed denied the allegations. According to staff R1 was provided care and services according to plan of care by facility staff and hospice. According to the centrally stored medication records, medication administration log and physician orders R1 was prescribed 0.5mg Lorazepam and not 3mg of Lorazepam. Interview conducted with potential witnesses revealed that R1 was provided good care and had no issues with any of R1's medications being dispensed by facility staff or hospice nurse. Random residents interviewed expressed being satisfied with the care services and report no issues with medications dispensed. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff is chemically restraining the resident" and "Staff are administering the resident medication without a doctor’s prescription” are deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.