complaint·November 20, 2025

Allegation #1: Staff are not trained to dispense medication. The complaint alleged that when a med tech calls out, untrained caregivers dispense medication to residents. On November 20, 2025, the Licensing Program Analyst (LPA) Richard interviewed the Administrator (A1), who denied the allegation and stated that the staff who assisted the residents with medication had been trained and held certificates to assist with medication. The LPA interviewed two Med Techs (MT1, MT2), who denied the allegation and stated that all the staff who assist the residents with medication are properly trained. They also noted that the caregivers do not have access to the Medication Carts. Additionally, the LPA interviewed four staff members (S1-S4), all of whom denied the allegation and asserted that they have not been trained and have not dispensed any medications to residents. Their duty is caregiving; only Med Techs give medications. The LPA also interviewed eight residents (R1-R8), all of whom expressed satisfaction with how the facility's staff administers their medications and stated that they have no issues with them. There is no specified time when a caregiver provides them with their medications. Furthermore, on November 20, 2025, the LPA reviewed the facility training medication documents from 2023, 2024, and 2025 for all Med Tech members who assist residents with their medications. Report Continued on LIC9099C Based on the interview, the records, and the information reviewed, there was insufficient evidence to support the allegation. Although the 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, the allegation is deemed unsubstantiated. Allegation #2: Staff are mismanaging residents' medication . The complaint alleged that staff members are mismanaging residents' medications, resulting in numerous errors that lead residents to refuse their medications. On November 20, 2025, LPA Richard interviewed A1, who denied the allegations and stated that only Med Techs assist with and manage the residents' medications. The LPA also interviewed two Med Techs (MT1 and MT2), who both denied the allegations. They stated that they follow the procedures outlined in the facility's internal training, which occurred from October 3, 2024, to September 14, 2025. They explained that if a resident refuses their medication, the Med Tech records it in the electronic medication administration record (E-Mar), contacts the family member and the physician, and disposes of the medication. Additionally, if medication is spilled by either staff or residents, they must contact the pharmacy to obtain a replacement and document this action in the E-Mar. Report Continued On LIC9099C On November 20, 2025, the LPA interviewed eight residents (R1-R8). Of these, five residents denied any issues with medication management. The caregiver never gave them any medication except Med Tech. On the same day, the LPA reviewed the MAR records of eight residents from 2025 and found no discrepancies in their medications. The LPA also reviewed the Med Techs' medication training, and all had completed it. The MT1 also explained to LPA how the processes of refused and/or spilled medications work. Based on the interview, the records, and the information reviewed, there was insufficient evidence to support the allegation. Although the 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, the allegation is deemed unsubstantiated. Allegation #3: Staff are not keeping accurate records of medication distribution. The complaint alleged that staff were backdating and forging their names on the residents' electronic Medication Administration Records (e-MAR) and on the hard-copy log for narcotics. On November 20, 2025, at 11:30 a.m., LPA Richard, Med Tech Martinez, and Santana inspected the medication room to review the resident supply and the medication cart. Upon examining a randomly selected resident's medication supply and records, LPA found the medication record to be accurate. Report Continued on LIC9099C The information documented in the electronic record matched the number of pills dispensed to the residents. Additionally, LPA reviewed the residents' medication records and found that all were signed on the day the medications were administered. Based on the interview, the records, and the information reviewed, there was insufficient evidence to support the allegation. Although the 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, the allegation is deemed unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the administrator, Nathan Boese.