Complaint Investigation Report

LPA Moleski reviewed daily notes pertaining to R1. A note written by S2 on May 30, 2025 stated the following: S2 attempted to wake R1 at 11:30 a.m. in order for R1 to take their medication, but R1 didn't wake up. S2 notified the administrator, who texted and called R1 in an attempt to wake R1. S2 continued to "go back and forth to wake up the resident" until noon. Later, S1 attempted to give R1 their medication. R1 woke up, got angry, and accused S1 of trying to shove medication in their mouth and attempting to hit R1. R1 called the administrator, reiterated these allegations, and called 911. Two administrators arrived later, and R1 took their medications. Nothing else of note was documented that day.

In an interview, S1 denied the allegations. S1 said that, on the morning in question, S2 had been unsuccessful in waking R1 to take their medications, so suggested that S1 try. S1 said they went to R1’s bedroom door and knocked, but did not enter. S1 said they explained to R1 that it was late, and asked if R1 wanted to take their medications. However, S1 said, R1 began screaming in response, alleging they were being forced to take their medications.

In an interview, S2 said that they had been periodically knocking on R1’s door for several minutes at a time on the morning of May 30, but R1 was not getting up. S2 said that when S1 arrived, around 2 p.m., S2 asked S1 to try to give R1 their medications. S2 said that they remained in the living room while S1 went toward R1’s room, so they didn’t see exactly what happened. However, S2 said they heard S1 entering R1’s room, S1 offering R1 medication, and R1 yelling in response. S2 said they saw S1 walk toward R1’s room with a glass of water and a cup of medication. S2 said S1 walked back from the direction of R1’s room with the same glass of water, containing the same amount of fluid.

In an interview at a new placement, R1 spoke positively about their time at this facility. R1 said that this facility was “more supportive about freedom,” and said they wanted to “make amends” and move back in. R1 said that two staff members (S1, S3) weren’t nice, but when LPA Moleski asked for clarification on what they did that wasn’t nice, R1 said they didn’t cook well. When LPA Moleski asked about the allegations made in this complaint, R1 said they were “not sure if it really happened.” R1 also gave contradictory statements. R1 said that they “felt water fall on” them, but also said that they were “the one who once threw water on them [the staff].”