Complaint·May 7, 2026

Investigation consisted of the following: On 2/5/2026 LPA reviewed and obtained Resident Roster dated 12/26/2025 which was updated during the visit with the current residents in care and staff roster dated 1/22/2026, Medication Administration Record (MAR) from 1/1/2026-2/5/2026 and Morphine Record from 7/5/2025 through 2/5/2026, Preplacement appraisal dated 3/14/2024,/RCFE levels of care assessment tool dated 3/14/2024, physicians report dated 3/19/2024, and updated appraisal/needs and services plan dated 1/20/2026 signed on 2/3/2026 electronically. As well as an random review of residents’ medication administration records (MAR) Investigation revealed the following: Allegation 2: Staff did not administer medication as prescribed. LPA conducted interviews with staff members 1-5(S1–S5) and 5 out of 5 stated residents’ medications are not mismanaged and residents are given their medications as prescribed by their physicians daily. LPA attempted to interview Residents 1–9 (R1–R9), who were asleep at the time of the visit. However, LPA was able to successfully interview Residents 10–11 (R10–R11) who stated they receive medication daily. When asked who gave their medication, they were both unable to provide details or names of staff members. LPA conducted a random review of residents’ medication administration records (MAR) and obtained documentation for R1. The records revealed that 5 out of 5 files reviewed reflects that the staff are managing residents’ medication and administering medications as prescribed by their physicians. Based on the interviews, records reviewed and observations the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is determined to be Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Irene Formentera at the conclusion of the visit with appeal rights.