Complaint Investigation Report

A review of facility records revealed that C1 is not permitted to self administer medication and that the OTC pain relief medication was not listed on C1’s physician’s orders. Additionally, a review of outside source records and interviews with C1 and outside sources (OS1 and OS2) disclosed that C1 went to the hospital on January 23, 2026; however, C1 interviews and records revealed that C1 called 911 independently. A record review confirmed that X-rays were performed, which revealed no fracture, and C1 was discharged back to the facility with a splint.

Based on the Department's investigation the evidence gathered during the investigation met the preponderance of evidence standard to prove the violations occurred. An exit interview was conducted with Caregiver Harrison, and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22 and LIC 9099D) will be provided at the conclusion of the visit.