Complaint Investigation Report

Interviews and review of communications between the facility and R1’s physician revealed that R1 was approved to self-administer and store multiple medications, including Temazepam. Interviews and medication orders revealed that R1 was approved to self-administer Temazepam until November 10th, 2023, and that facility staff began administering R1’s Temazepam on November 10 th , 2023. Interviews with staff and outside sources revealed that after R2’s eviction, R1 was relocated to another apartment within the facility. During the move, staff searched R1’s apartment for any medications and located several medication bottles which were entered into the facility’s central medication storage, including a bottle of Temazepam. Interviews with staff and outside sources revealed that prior to November 10 th , 2023, R1 was permitted to reorder medications and it was possible that R1 had ordered an additional bottle of Temazepam that staff were not aware of and had not found during R1’s move to a different apartment. Additionally, R1’s prescription for Temazepam was written to be administered as needed, which allowed for the possibility for R1 to have multiple bottles of the medication if R1 ordered new bottles monthly, which R1 was approved to do. Interviews with staff and outside sources did not reveal concerns that staff had intentionally neglected to collect all medications from R1’s possession once R1 was no longer approved to self-administer and R2 had a history of hiding R1’s medications while R2 was living with R1.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).