Complaint Investigation Report

LPA De Leon reviewed the emails which revealed the previous Administrator was setting up medication training for a list of staff handling medications. The email chain did not have set dates for training to be held or completed, and the emails were dated 09/2024. The prior administrator no longer works at the facility as of 11/2024. LPA Kontilis never received staff medication training records during the investigation. LPA De Leon requested 2024 medication training records on 11/13/2025 from the new Administrator as of 10/19/2025 no medication records were produced. Due to the lack of evidence with training records for medication staff this allegation is Substantiated .

On the allegation: Staff mishandled a resident's medication, LPA Kontilis was provided with the facility’s internal investigation report, at the time the investigation was ongoing and had not been completed. LPA De Leon requested the completed investigation report and any staff disciplinary records on 11/13/2025, Administrator provided one staff members disciplinary record which did not involve a medication error. LPA De Leon reviewed the emails, medication records and photos which revealed the Resident 1 (R1) handled and stored R1’s own medications when moving into the facility on 09/27/2024, the medication order was for Amiodarone HCL 200mg – 1 tab by mouth twice a day and was prescribed by R1’s Cardiologist. On 10/09/2024 Staff notes communicate that R1 was having confusion with medications and staff felt it should be centrally stored by the facility. On 10/12/2024 the facility took over R1’s medication and Staff 1 (S1) took a telephone order from another doctor for Amiodarone HCL 400mg – 1 tab by mouth twice a day. The doctor’s office was contacted by the facility during the investigation to ask if the telephone order was correct, the office told the facility that they did not do a phone order for that medication for R1. On 10/22/2024 the cardiologist wrote an order for the medication Amiodarone 200mg – 1 tab by mouth twice a day. The medication Amiodarone 400mg – 1 tab by mouth twice a day was provided to R1 from 10/12/2024 until 10/23/2024. The record keeping of medications and orders was not being done timely and several orders were not confirmed by the prescribing physician which was a communication breakdown between the facility and the providers which is required when the medications for the residents are being centrally stored, and the staff are aiding the residents with taking medications. Residents pay additional fees to have the medication managed by the facility and the lack of communication was the issue with this medication being given. Based on the evidence this allegation is deemed Substantiated at this time.