Complaint Investigation Report

Further review shows approximately 15 medication bottles and a bubble pack placed on a wooden chair near the facility cabinets, making them accessible to residents. Although staff reported that medications were secured, the recording also shows that no staff members were awake at the time. Based on the information gathered, the facility staff did not store medications locked and inaccessible to the residents in care.

Allegation: Staff were asleep and left residents without supervision while in care.

It was alleged that staff were asleep and left residents without supervision while in care. During the course of this investigation, the department conducted interviews and reviewed video recordings. Interviews with two staff members indicated that staff were not asleep and that residents were not left without supervision. However, statements from outside parties reported that a responsible party arrived at the facility and was able to gain entry with assistance from a resident. Upon entry, the responsible party observed S1 seated in the middle recliner with their eyes closed.

Recordings obtained from approximately 01/13/2026 further contradict staff statements. The video shows one resident in a recliner, one resident in a wheelchair, and two residents in a separate room. Additionally, upon entry into the living area, a male staff member wearing a dark green sweater and light-colored jeans is observed with his legs propped up and eyes closed, appearing unaware that a recording was being made at that time.

Based on the information gathered, the staff were asleep and left residents without supervision while in care.

Allegation: Staff did not ensure that hazardous objects were inaccessible to residents in care.

It was alleged that staff did not ensure that hazardous objects were inaccessible to residents in care. During the course of this investigation, the department conducted interviews and reviewed video recordings. Based on interviews conducted, it was denied by 2 staff members that they did not ensure that hazardous objects were inaccessible to residents in care. It was stated that residents were unable to access the kitchen without staff knowledge however, further interviews revealed that around 01/13/2026, the kitchen was accessible to residents. During a family visit, items such as knives were observed, and the stove was on. Additionally, the staff member present at that time appeared to be asleep. A review of video footage confirmed that the kitchen was accessible to the visiting family member and showed a large silver knife on a cutting board with two pieces of zucchini beside it, along with the gas stove turned on.Based on the information gathered, the staff did not ensure that hazardous objects were inaccessible to residents in care.