Complaint Investigation Report

Interviews were conducted with care staff members and the administrator, Jonathan Li (AD). Care staff interviews indicated the medication was a cream for a toenail problem, given to a resident (R1). Care staff explained that they usually receive about any changes in medications from the administrator. They said they didn’t know the medication had been stopped because they hadn’t been told in time, so they kept giving the medication to R1.

The administrator explained that R1’s parents are responsible for all of R1’s medical and dental appointments. Since taking over as the new administrator, AD hasn’t gone to those appointments. He depends on R1’s parents to send him updates after visits, including any medication changes. Jon confirmed that the cream (Tolnaftate) was stopped back in March 2025, except for a brief period from 10/2/25 to 10/4/25, when the medication was mistakenly resumed based on an “After Visit Summary” received from R1’s parents. This version of the summary, printed on 9:57 AM on 10/2/25, listed Tolnaftate in the active medication list, leading staff to believe the medication was reinstated. When AD sought clarification and received a second version of the same After Visit Summary, printed later at 10:31 AM, it clearly indicated that Tolnaftate was discontinued. The medication was immediately stopped upon this clarification.

A review of R1’s medical records support this timeline. The Medication Administration Record (MAR) shows that Tolnaftate was regularly administered from December 1, 2024, through March 25, 2025, and not administered from March 26, 2025, through October 1, 2025. It was briefly administered again between October 2, 2025, and October 4, 2025, during the period of confusion regarding the medication's status. Additionally, R1’s Physician’s Report dated April 10, 2025, indicates that R1 is capable of self-care, including managing own medications.

Based on the interviews and records reviewed, there is insufficient evidence to support the allegation that staff were knowingly administering a discontinued medication to R1. The temporary administration of the Tolnaftate cream in October 2025 was due to conflicting documentation and was promptly corrected once accurate information was received. Therefore, the allegation is unsubstantiated .

Technical Violation was issued and advisory was provided to Administrator to ensure any new medication orders are clarified and confirmed by residents' prescribing physician before residents start the medication.

Exit interview was conducted and a copy of this report and appeal rights were provided.