It was alleged that R1 was hospitalized on August 23, 2025, after becoming unresponsive due to being given an excessive dose of Ambien that interacted with other medications. During the investigation, the Administrator and staff reported that all medication procedures were followed and confirmed that R1 was not prescribed or given Ambien. Staff reported no medication errors or unusual incidents on the day in question. Six (6) residents also expressed no concerns about medication administration. Review of facility Centrally Stored Medications and Destruction Record (CSMDR) showed no discrepancies and no doctor’s order for Ambien for R1. Hospital records indicated R1 was admitted for possible cardiac arrest of unknown cause and treated for sepsis secondary to a UTI, with no indication of an overdose. Based on interviews and record reviews, the allegation was determined Unsubstantiated at this time.

Allegation: Staff overdosed resident

It was alleged that R1 was hospitalized on August 23, 2025 due to being given an excessive dose of Ambien. The Administrator and staff reported that R1 was not prescribed Ambien and that all medication procedures were properly followed. Staff confirmed that medications were securely stored, accurately logged, and administered according to physician orders. Six (6) residents interviewed expressed no concerns about medication administration. Review of the facility’s medication records showed no discrepancies and confirmed that no Ambien order existed for R1. Hospital records indicated R1 was admitted for possible cardiac arrest of unknown cause and treated for sepsis secondary to a UTI, with no documentation of any overdose. Based on interviews and record reviews, the allegation was found to be Unsubstantiated at this time.

Continue on LIC9099-C

The allegation stated that R1 was hospitalized on 8/23/25, transferred to a skilled nursing facility (SNF) on 8/27/25, and when ready for discharge on 9/09/25, the Administrator refused R1’s return even though rent had been paid. During the investigation, the Administrator reported that R1 experienced multiple medical issues, including a UTI, a fall at the SNF on 8/31/25 resulting in a closed head injury, and a subsequent return to the hospital. R1 was discharged back to the SNF on 9/02/25. The Administrator also stated that R1’s physician (from the hospital) informed him that R1 required a higher level of care and could not safely return to the facility. After receiving that information, the Administrator did not cash R1’s rent check and immediately notified R1’s family/POA. LPA was provided with the progress note from the facility, dated on 09/02/25, where indicated the following: "Due to R1's current condition and care needs, R1 was not appropriate to return to the Board and Care facility, R1 requires higher level of care... R1 requires one-on-one care and supervision to adequately meet their needs." LPA also conducted review or R1's discharge records from the hospital and observed that on 09/02/2026, R1 was discharged back to Skilled Nursing Facility for ongoing management (i.e. the facility provides round-the-clock nursing supervision, medical monitoring, and restorative therapies that cannot yet be safely managed at home). Therefore, based on interviews and record reviews this allegation is deemed Unsubstantiated at this time.

No deficiency issued during today's visit.

Exit interview conducted and copy of this report signed and delivered.