Complaint·April 1, 2026

Two of four resident records (R3-R4) Medication Administration Records (MAR’s) revealed to be current and complete. Records for R2 were completed by facility staff and Hospice staff. MAR’s for R1 were provided for December 13, 2025 to February 23, 2026 and LPA observed that medications for R1 for December 13, 2025 to December 31, 2025 were initialed and signed off by Staff1. A as needed PRN MAR for same dates of December 13-31 st was also provided with three PRN (as needed meds) for R1. LPA observed the PRN MAR had signatures for one medication by staff 1. LPA observed that it was unclear what PRN medication was signed off by Staff 1 due to signature was signed on a line that was in between two medications (Lactulose and Olanzapine). R1’s MAR for month of January 2026 was signed off by two different staff members (S2 & S6). One medication for R1 (Nitrofurantoin) was missing signatures from January 7-19, 2026. R1’s MAR for the month of February 1-23 rd was signed off by two staff members (Staff 2 and 5). R1’s MAR for February was missing signatures for three PM medications (Levothyroxine, Synthroid, and pantoprazole) on February 23rd. Medication Training verification was provided for four of six staff members of which four staff administered meds to R1. Interviews conducted with staff revealed that staff stated they verify one by one medications for AM, NOON and PM medications before dispensing to each resident one by one. Staff interviews stated that once medications are dispensed to residents and they visually see that Residents have swallowed medications, Staff sign off MAR for given meds. Staff interviews stated that if Resident refuses medications or are out of facility in example if they are out at hospital, MAR should not be signed off if medications are not dispensed. Interviews with three staff members stated they had Medication Training. Interview with Staff 1, stated that due to S1 no longer working at facility, S1 could not recall and wished not to disclose information regarding medications given to residents. Interviews with two residents R3-R4 stated that they receive their medications timely and have no issues regarding medications or staff. Interview with Witness 1 revealed that staff members were incorrectly filling out Resident MAR’s and stated that medication was listed that Resident was not supposed to be given. Based on information provided in investigation, the preponderance of evidence has not been met, deeming the allegations Staff do not ensure medication records are properly maintained to be Unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred as reported. An exit interview was conducted with Administrator Abalia and copy of report was discussed and provided.