complaint·December 30, 2025

Interviews revealed that on 5/20/2025, three days following R1’s admission to the facility, R1 was observed to have a change in condition, which resulted in emergency services being contacted and R1 was transported to the hospital. Medical records from R1’s hospitalization showed that toxicology results revealed that R1’s urine analysis was positive for fentanyl. Review of R1’s medical records revealed that R1 was not administered fentanyl during emergency services transport or while at the hospital prior to the toxicology test. Review of the medication lists for all residents at the facility, including for R1, did not reveal any medications that contained fentanyl. During interviews, staff denied any knowledge of the existence of any medications containing fentanyl in the facility, including medications prescribed to live-in staff. Staff also denied knowledge of how R1 could have been exposed to fentanyl while at the facility. Review of R1’s toxicology report confirmed that medications of a similar chemical structure to fentanyl could cause a false positive on testing. Interviews with medical professionals denied that any of R1’s prescribed medications could cause a false positive for fentanyl. Clinical consultants of the Department also reviewed R1’s medications and confirmed that none of R1’s prescribed medications could cause a false positive for fentanyl. Additionally, medical professionals stated that fentanyl is generally prescribed in patches applied to the skin and other forms of administration such as liquids or pills are rarely prescribed. R1’s toxicology report stated that the test was “unconfirmed screening results” used to assist in managing medical care and additional testing would need to be done to confirm the result. Review of R1’s medical records did not reveal any evidence that confirmatory testing was ordered to verify if the test was accurate. The Department has investigated the above-mentioned allegation and based on interviews and records review showing a lack of evidence of mismanagement of medications and a lack of explanation of how R1 tested positive for fentanyl, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Caregiver William Punta , whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).