complaint·February 12, 2026

(Continued from LIC9099C 3 of 3) MARs reviewed showed medications administered as prescribed, with no discrepancies noted. Incident and complaint logs for the past six months contained no substantiated reports of medication errors or unqualified staff administering medications. LPA observations during the visit confirmed that medications were stored securely in locked cabinets and carts, and medication passes were conducted by staff wearing name badges indicating their role. No unqualified staff were observed handling medications. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Susan O'Shaughnessy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 2 of 3) Residents confirmed that care is provided as scheduled, call-light response is prompt, and no delays have impacted their safety or comfort. Outside sources, including a family member, hospice nurse, and ombudsman, stated they observed adequate staff presence and timely care delivery, with no concerns regarding staffing adequacy. Records reviewed included staffing schedules, timecards, call-light response reports, resident service plans, medication administration records, and incident logs for the past six months. Documentation showed scheduled coverage consistent with resident needs and no substantiated complaints related to staffing. LPA observations during the visit confirmed staff were present and actively assisting residents with ADLs and mobility. Call-light spot checks demonstrated responses within three to six minutes, and no unattended residents or signs of unmet care needs were observed. On 9/4/25 it was alleged that unqualified facility staff administered medications to the residents. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. I nterviews were conducted with three staff members, three residents, and three outside sources. All staff interviewed stated that only trained and authorized personnel administer medications, and confirmed they have completed required medication training per facility policy and Title 22 requirements. Staff reported that medication administration is documented in the Medication Administration Record (MAR) and overseen by supervisory staff. Residents interviewed stated they receive medications on time and have not observed or experienced untrained staff giving medications. Outside sources, including a family member, hospice nurse, and ombudsman, reported no concerns regarding medication administration practices and confirmed that medications appear to be managed appropriately. Records reviewed included staff training logs, medication competency checklists, medication technician certificates, MARs, and facility policies on medication administration. Documentation confirmed that staff assigned to medication duties have completed required training and competency evaluations in accordance with regulations.