Complaint Investigation Report

On 9/16/2024 LPA Mason conducted a visit to the facility. LPA obtained electronic copies of the staff roster dated 6/6/24, resident roster dated 6/4/24, Staff schedule for the month of September 2024, Admission Agreement, Preplacement Appraisal, Dangerous Propensities document, Individual Program Plan, Functional Capabilities Assessment, Hospital visit summary and record of medical care.

LPA conducted interviews with Administrator and 2 staff (S1, S2). During 2 of these 3 interviews, facility staff stated C1 obtained a knife in the facility on 9/3/2024. On 11/6/2024, LPAs returned to the facility and conducted interviews with AD2 and one staff (S3). S3 stated C1 obtained a knife in the facility on 9/3/2024. AD2 and S3 stated a work order was made to add a component to the knife drawer lock to prevent it from being forced open. AD2 provided LPAs with a copy of the completed work order for the lock drawer. LPAs conducted interview with C1. C1 confirmed that they did obtain a knife in the facility on 9/3/2024. Of the 6 interviews conducted with AD1, AD2, C1, S1, S2 and S3, 5 out of 6 interviewed stated they were aware that C1 obtained a knife in the facility on 9/3/2024.

The preponderance of evidence standard has been met. The allegation is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.