Complaint Investigation Report

During interview, R1’s Psychiatrist, Witness 4 (W4) stated they have been R1’s psychiatrist since December 18, 2023 to manage R1’s depression and Bipolar I. Per W4, they see R1 both in person and online once a month, or more often, if further care is needed. W4 stated R1’s last visit was on February 18, 2026 and was an in-person visit. Per W4, they have prescribed anti-depressants to help R1 manage their depression, which R1 has been off and on since 2023. W4 stated that during R1’s October 2025 appointment, they noticed R1 was withdrawn, was non-responsive to questions, and was unable to verbalize their care and as a result re-prescribed anti-depressants for R1. Per W4, at R1’s November 2025 appointment, they began to see a slight improvement in R1’s demeanor, but by R1’s January 2026 appointment, R1 was again displaying signs of mental decline. W4 stated as of their February 18, 2026 appointment, they are still actively altering R1’s medications to support their change in condition. Per W4, R1 has never been reported to use drugs or alcohol as a coping mechanism by facility staff, nor is the use of either substance allowed in the facility. W4 stated that when they alter R1’s prescriptions, they take note of the other medications R1 is being prescribed by other providers. Per W4, they did note that R1 has been recently prescribed antibiotics due to chronic UTIs and stated that although not common, antibiotics and NSAIDs such as Advil, Aleve, and Ibuprofen have been known to present a false reading for Cocaine on a drug screening.

During interview, Nurse Practitioner, Witness 5 (W5) stated they have been R1’s care provider since approximately September 2025. Per W5, while they have been overseeing R1’s care, R1 has primarily been treated for UTI and stated there have been no other concerns regarding R1’s health, nor have any concerns been raised regarding R1’s medications. Per W5, R1 has never had a history of drug use, nor had a positive drug test. W5 stated due to R1’s cognitive impairment, they do not believe R1 has the mental capacity to access or use drugs and described R1 as having an almost comatose baseline and unable to care for themselves without supervision.

Based on R1’s diagnoses, they require constant care and supervision and do not have access to use illegal narcotics. R1 is also prescribed 13 different medications, including Benzodiazepines and antibiotics, which could produce a false positive in a drug screening.

Based on gathered information, the Department did not find sufficient evidence to support the allegation, “Resident used illegal drugs resulting in hospitalization.” Although the above 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 at this time the above allegation is Unsubstantiated.

An exit interview was conducted and copy of this report was provided at the end of the inspection.