Complaint Investigation Report

S1 also provided a carrier-generated text log, which confirmed that no text messages were received from R1 between June 13, 2025 and June 18, 2025. Review of R1’s phone showed that a text message was sent to S1 on June 17, 2025 but did not show a delivery confirmation and may not have been successfully transmitted. S1 also reported that both staff were asleep at the time the message was sent, and no one attempted to wake them to report an emergency.

There is conflicting information regarding the allegation that staff failed to respond to an emergency. Both S1 and Staff 2 (S2) stated that they did not administer an EpiPen to R1. LPA could not verify whether an EpiPen was administered. Review of R1’s medication showed an unopened EpiPen prescribed to R1 in November 2024. During interview with R1, they stated that staff appeared unfamiliar with how to administer the EpiPen and used a YouTube video for guidance. Review of S1’s file showed that they have training on medication administration and has a nursing diploma. Based on interviews conducted record review, and observations made, these allegations are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Exit interview conducted. Copy of report discussed and provided to the Administrator. The signature on