The complaint alleged that the resident R1 has not received R1's medication for a month. On August 4, 2026, the LPA interviewed the Licensee regarding the allegation. The Licensee denied the allegation and stated that the medication had not been delivered to the facility; therefore, staff could not administer it. During the same, LPA interviewed the Administrator (A1), who denied the allegation, stating that on June 30, 2026, A1 had called Witness (W1) to inform them that the medication refill for R1 had not been received after W1 took R1 to the doctor. At that time, R1 only had half a month's worth of medication left.

On July 14, 2026, A1 called W1 again about the facility not having received the medications. W1 indicated that the doctor had already sent the order to the pharmacy. After this, A1 contacted the pharmacy and learned that the doctor had mistakenly sent the order to the wrong pharmacy. A1 then had to call the doctor's office to request a new order be sent to the correct pharmacy. A1 explained that this was the reason R1's medication could not be administered. Finally, on July 29, 2026, the doctor's office verbally ordered the medications, and the facility received the medications the same day.

On August 4, 2026, LPA interviewed 2 Medical Technicians (MT1-MT2), all of whom denied the allegations and stated that they ensure all resident medications are administered on time and that they follow the doctor's orders. Additionally, LPA interviewed 3 staff members (S1-S3); they all denied the allegations and stated that Med Tech assisted with medication they do not assist with meds.

On August 4, 2026, the Licensing Program Analyst (LPA) reviewed the ALIS Medication Administration Records (E-MAR) for July 2026 and noted that the medication was on hold from July 14 to July 29, 2026. During this review, the LPA also examined facility notes, which indicated that A1 made three calls to W1 regarding the facility not receiving the medication for R1 from the pharmacy. On the same day, August 4, the LPA contacted the pharmacy witness (W2), who confirmed that they received a verbal medication order from the doctor's office for R1 on July 29, 2026.

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 unsubstantiated.

Report Continued on LIC9099C

The complaint alleged that resident R1's three medications were on hold for a month while staff logged them as administered. On August 4, 2026, the Licensing Program Analyst (LPA) interviewed the Licensee, who denied the allegation. The Licensee stated that the facility used the ALIS Medication Administration Record (MAR), an electronic medication administration record (E-MAR). They explained that staff could not falsify records if the medications were not actually available.

Additionally, the Administrator denied the allegation, stating that the medication technicians could not falsify records because the resident's medications were placed on hold until the facility received the necessary orders, a fact clearly documented in ALIS. During the same visit, the LPA interviewed two Medical Technicians (MT1 and MT2), who corroborated the denial of the allegations. They explained that they had to initial the Medication Administration Record (E-MAR) and indicate an exception mark whenever a medication was not administered due to being on hold.

On August 4, 2026, the LPA reviewed the ALIS Medication Administration Record (E-MAR) for the period from July 14, 2026, to July 29, 2026. The record indicated that the scheduled time, recorded time, and reason for not administering the medications were all marked as on hold. The LPA also confirmed that the Med Techs' Certificates of Completion are on file.

Report Continued on LIC9099C.

No deficiencies were cited.

An exit Interview was conducted. A copy of this report was provided to Administrator Mascardo Ma Luisa.