Complaint Investigation Report

Allegation – Due to neglect/lack of care and supervision, residents had access to illegal drugs. The investigation into this allegation consisted of interviews and record reviews.

Based on an interview with a witness (W1), on 11/14/2025, residents R1 has been known to have methamphetamine in their possession and has distributed methamphetamine to R2. Interviews revealed that within one week of moving into this facility, R1 displayed behaviors consistent with drug use. R1 went on outings, and returned to the facility erratic, grinding their teeth, swearing, and having red eyes. According to one facility staff member, R1 would return to the facility appearing high on drugs and bringing back “crystal rock.” Staff interviews confirmed they had not seen R1 with drugs but seen R1 with a “pipe.”

Records for R1 show a history of substance abuse. R1’s Medical Assessment dated 8/15/2025 documented that R1 was diagnosed with substance abuse disorder and polysubstance self-abuse. The assessment also stated that R1 was able to leave the facility unassisted. R1’s Needs and Services Plan dated 8/13/2025 did not include a plan for how the facility would manage or address R1’s illegal substance abuse. R1’s court documents dated 8/12/2025 showed R1 had a scheduled court appearance for unlawful possession of methamphetamine, criminal threats, and felony-level elder abuse.

Facility daily notes from 10/10/2025 to 11/11/2025 were also reviewed. On 11/10/2025. R1 told staff that they went to buy drugs and said they had shared the drugs with other residents in care. On 11/11/2025, staff documented that R1 was giving methamphetamine to other residents around 3:00 AM. It was also noted that R1 and R2 left the facility at around 3:30 AM.

Police records dated 11/12/2025 further confirm concerns of drug use. Officers responded to the facility after receiving a report that a resident was possessing and distributing methamphetamine. Staff on duty reported that R1 admitted to using methamphetamine and giving it to two other residents. During a search of R1’s bedroom, officers found burnt foil and a plastic blue straw, which are commonly used to ingest drugs such as methamphetamine, heroin, or fentanyl. R1 was taken into custody for possession of drug paraphernalia and stated that they used the foil and straw to smoke drugs.

The facility’s house rules state that possession of illegal drugs is prohibited. However, records and interviews show that R1 continued to leave the facility, obtain drugs, return to the facility while under the influence, and share drugs with other residents.

Based on the interviews, records reviewed, and police report, the allegation that residents had access to illegal drugs due to neglect and lack of supervision is substantiated.