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32 | Continued from LIC9099
was being mentally brutalized and psychologically tortured due to being forced to take medication, having facility staff knock on their door three times a day for medications, and being charged $900 per month for care they did not need.
“Personal Rights” – Interview with Resident 1 (R1) stated that it is wrong that facility staff are coming into their room to bother them about medications. Per R1, they have told facility staff that they don’t want medication, but facility staff keep coming to their room and keep pushing them to take medication. R1 stated that after refusing, facility staff leave with the medication.
Review of facility’s policy under “The Six Rights” stated that the seventh right that a resident has is the “Right to Refuse.” Per facility document, residents may refuse medication at any time for any reason, but facility staff should try at least three times. Review of facility documents showed that R1 has been refusing their medications and facility has been notifying their primary care physician of the refusals.
Review of R1’s file indicated that the facility received communication from R1’s Psychiatrist on 03/20/2026. Per communication, the facility has been directed to continue administering R1’s medication per physician orders based on R1’s medical history and to keep R1 on the facility’s medication management program.
“Facility did not provide resident explanation of additional services when initiating a new level of care” – Review of R1’s file showed that they moved to the community on 02/14/2026. Per facility documents, R1’s initial level of care was assessed at a Level 1 on 02/12/2026. R1’s care included being on the facility's medication management program, having showers two times per week, escorts, and reminders. Per facility email correspondence, R1’s level of care would be reassessed after 30 days for accuracy. On 03/10/2026, R1’s level of care was lowered to a Level A and included being on the facility's medication management program. Further review of R1’s Level A care plan showed that R1 signed the document on 03/10/2026, indicating that they were informed of the care changes made. Review of R1’s financial transaction report indicated that from February 2026 to May 2026, R1 has not been charged an additional $900/month.
Based on record review, interviews conducted, and observations made, this allegation is Unfounded. A finding of Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
Exit interview conducted. Copy of report discussed and provided to Executive Director, Interim Resident Care Director, and Resident Care Director. Signature on form confirms receipt of documents.
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