During the investigation, LPA reviewed R1’s file and all the documentation related to R1, interviewed the Administrator, S1 - S4 and R2 - R3. LPA reviewed R1's records and observed that R1 has a documented psychiatric diagnosis and was prescribed Risperidone 0.5 mg, which was later increased to 1 mg by R1's psychiatrist.

Interviewed Administrator and staff stated that R1's DPOA was routinely involved in communications regarding R1's medications, behavioral changes, and medical care. The Administrator stated that R1 was previously prescribed Risperidone 0.5 mg. On 05/22/2026, the facility received a new prescription for Risperidone 1 mg from the pharmacy. The DPOA was notified by text message the same day and subsequently provided the psychiatrist's order by email confirming that the 1 mg prescription replaced the previous 0.5 mg dosage. The Administrator stated that facility staff do not independently change medications and only administer medications pursuant to physician orders. Interviewed S1 stated that the DPOA was consistently informed regarding R1's medications and care. S1 stated that all medication changes were based on doctor's instructions and that facility staff never independently changed R1's medications. Interviewed S2, S3, and S4 stated that staff routinely report changes in residents' conditions to the Administrator and S1, communicate with them regarding medication related matters, and administer medications only according to current doctor's orders. Staff stated they do not independently change or discontinue medications. LPA interviewed R2 and R3. R2 and R3's interviews did not corroborate the allegation. LPA reviewed and obtained copies of text messages and email communications between facility staff, Care team / Medical Group and R1's DPOA, which confirmed that R1's DPOA was informed of the new Risperidone prescription and DPOA informed facility staff that the psychiatrist had changed R1's Risperidone dosage from 0.5 mg to 1 mg and provided the psychiatrist 's written order authorizing the dosage change. LPA also reviewed R1's medication records, which were consistent with the physician's orders.

Although the allegation may have happened or is valid, there is insufficient evidence to support the allegation that staff changed R1's medication without consent from the authorized representative. Therefore, the allegation is deemed Unsubstantiated.

During the investigation, LPA reviewed R1’s file and all the documentation related to R1, interviewed the Administrator, S1 - S4, R2 and R3. LPA reviewed R1's records and observed that R1 has a documented psychiatric diagnosis and was prescribed Risperidone 0.5 mg, which was later increased to 1 mg by R1's psychiatrist. Interviewed Administrator and staff stated that the facility maintained regular communication with R1's DPOA regarding R1's medications, behavioral changes, and overall condition. Administrator stated that R1 was previously prescribed Risperidone 0.5 mg and that the DPOA was notified on 05/22/2026 when the facility received the new prescription for Risperidone 1 mg. The Administrator further stated that on 05/28/2026, after R1 developed hand tremors, shakiness, difficulty walking, and an unsteady gait, staff immediately contacted the psychiatric clinic. Later that day, the psychiatrist instructed the facility to place Risperidone 1 mg on hold until R1's scheduled psychiatric appointment / evaluation on 06/01/2026. Administrator stated that the DPOA was informed of R1 symptoms and of the doctor's hold order. Interviewed S1 stated that after observing R1's symptoms, they immediately contacted the psychiatric clinic and notified the DPOA by text message regarding R1's condition. After receiving doctor's written order to place Risperidone 1 mg on hold pending R1's appointment / evaluation on 06/01/2026, S1 again notified the DPOA, who acknowledged receiving the information. Interviewed S2, S3, and S4 stated that after observed changes in R1's condition, including hand tremors and difficulty walking, reported those observations to the Administrator and S1, and were informed that Administrator and S1 had contacted both the psychiatric clinic and the DPOA. Staff further stated they were informed that R1's doctor ordered the medication to be placed on hold until the scheduled appointment on 06/01/2026. LPA interviewed R2 and R3. R2 and R3's interviews did not corroborate the allegation. LPA reviewed and obtained copies of text messages and email communications between facility staff, Care Team / Medical Group and R1's DPOA. The communications confirmed that the DPOA was notified of the new medication dosage, R1's change in condition, and the doctor's order placing Risperidone 1 mg on hold pending the psychiatric appointment on 06/01/2026. Although the allegation may have happened or is valid, there is insufficient evidence to support the allegation that staff failed to notify R1's authorized representative of medication changes. Therefore, the allegation is deemed Unsubstantiated.

Interviewed Administrator and staff stated that after they observed that R1 developed hand tremors, shakiness, difficulty walking, and an unsteady gait, they contacted the psychiatric clinic to report R1's condition. The Administrator stated that the facility subsequently received the psychiatrist's written order directing staff to place Risperidone 1 mg on hold until R1's scheduled psychiatric appointment / evaluation on 06/01/2026. The medication was labeled "HOLD," staff were notified of the doctor's order, and the facility followed the doctor's instructions. Interviewed S1 stated that after reporting R1's symptoms to the psychiatric clinic, the facility received the psychiatrist's written order directing staff to place R1's Risperidone 1 mg on hold pending R1's psychiatric appointment / evaluation on 06/01/2026. S1 immediately informed the Administrator, notified the DPOA, and advised all staff of the doctor's order. S1 stated that facility staff do not independently discontinue medications and administer medications only according to doctor instructions and written orders. Interviewed S2, S3, and S4 stated that they always administrate all residents medications according to doctor’s order. They stated that Risperidone 1 mg was on hold by R1’s doctor and they continued to administer medications only in accordance with current doctor's orders and facility medication procedures. LPA interviewed R2 and R3. R2 and R3's interviews did not corroborate the allegation. LPA reviewed R1's Medication Administration Record (MAR), doctor's medication orders, and related medication records, which confirmed that facility staff followed the doctor's written order by placing Risperidone 1 mg on hold pending R1's psychiatric appointment on 06/01/2026. LPA also reviewed text messages and email communications documenting the doctor's order and notification to the DPOA.

Although the allegation may have happened or is valid, there is insufficient evidence to support the allegation that staff did not follow R1's doctor's medication orders. Therefore, the allegation is deemed Unsubstantiated.

Exit interview is conducted and the copy of this report was provided.