Complaint Investigation Report

During a 08/22/2025 facility visit, LPA observed that the staff bedroom door was left unlocked, and just inside this door were multiple pill sorter/organizer containers with pills inside. LPA was then able to enter the bedroom and remove/confiscate medications without any of the staff observing him do it. LPA then handed the medications back to staff, instructing them to resecure them inside the locking drawer which Licensee has designated for central medication storage. Interviews of 3 of 3 staff at the facility on 08/22/2025 confirmed that said pills belonged to the clients in care. Interviews of 5 of 5 clients corroborated that the staff typically transferred clients’ medications to these pill organizer containers, from which they were then dispensed to clients, instead of staff keeping the pills in the original pharmacy-labeled blister-pack packaging. (Regulation requires centrally stored medications to be stored “in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.” Regulation also requires that “each client's medication shall be stored in its originally received container.”)

Interviews of multiple managers and staff aligned to show: Staff #1 (S1) had neither formal training nor the skill/knowledge to independently pass medications to the clients. On a day in late July 2021, C1 needed/requested an as-needed (PRN) anti-anxiety medication, but S1 could not dispense said PRN from C1’s blister-pack. C1 had to wait for Staff #3 (S3), who themselves were trained to assist with medications but also away on a grocery store run, to come back to the facility to give C1 their PRN. While S3 ultimately gave C1 their PRN, the incident represented an unnecessary delay in C1 receiving needed medication assistance. A similar delay occurred on 09/13/2025, when S1 was again the lone staff, and S3 had to come back to the facility to give C1 their PRN. The Complainant also claimed that for approximately three weeks from late August 2025 to early September 2025, Licensee had run out of medications to give to C1 and that Licensee’s staff did not timely contact C1’s responsible person or physician to resolve the delay. However, interviews of C1 and relevant staff, along with LPA’s own audit of C1’s prescribed (RP) medication list and blister-packs, showed otherwise (meaning there was not a preponderance of evidence to support that C1 had gone without medication due to running out if pills in inventory).