Complaint Investigation Report

3 out of 3 staff stated S1 was a caregiver at the facility and a live in staff. 3 out of 3 staff stated S1 cooked, cleaned and assisted residents with ADLs. ADM and S2 stated S1 was trained to administer medication from the day he/she started and was provided hands on training. ADM stated S1 was trained according to regulation and S1 did not like signing any documentation. S2 stated he/she also trained S1 in medication management and direct support staff duties. 1 out of 3 residents stated he/she recalls S1 not wanting to sign documents but was not able to state what documents.

LPA reviewed S1s file and S1 was CPR certified as of January 30, 2026. S1 also received training but refused to sign orientation checklist sheet. S1 agreed to train new staff when he/she resigned and when new staff were hired. Based on interviews S1 did receive hands on training in administering medication.

1 out of 3 residents’ medication record showed resident was given medication per doctor’s orders. R1 stated he/she took all his/her medication according to doctors’ orders. LPA reviewed medication record for R1 which showed ADM signature on medication administration record and medication was dispensed as prescribed. LPA conducted an audit of R1s medication and found no discrepancies. ADM stated R1 did have PRN medication, and it was destroyed after R1s symptoms subsided.

1 out of 3 residents stated that they see the Administrator (ADM) at the facility everyday and he/she leaves the facility around 3 PM. 1 out of 3 residents stated that ADM is at the facility for 1 hour. 1 out of 3 staff stated ADM is at the facility during the day when Residents are at day program and leave’s around 3 PM. LPA reviewed the Staff schedule for January, February and March which shows the administrator is at the facility from 3-11 PM. S3 stated ADM has a scheduled appointment every day at 3 PM and returns to facility and stays till around 9 PM. ADM provided a weekly schedule for week of April 19, 2026, which states ADM is at the facility from 6-10 AM and between 7-9 PM

On April 24, 2026 the department concluded its investigation.

Based on investigation, interviews conducted, and records reviewed, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

This report was reviewed with Administrator and a copy of the report was provided.