Complaint Investigation Report

LPA's interview with seven (7) staff members, including the Administrator reflected that when medications are administered, one (1) staff member administers the medication and signs the medication record. A second staff member reviews the record within approximately 15 minutes to confirm that the medication was administered. Staff also reported that medication audits are conducted three times daily. At the end of each week, the Administrator conducts an additional audit to verify that medications were administered as prescribed. Interviews further revealed that no staff has ever observed a client in care miss a medication at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not administer resident's medications as prescribed” is deemed Unsubstantiated at this time.

It was reported that "Facility unable to meet the needs of a client in care" as it was alleged that Client #2 (C2) hits staff and throws feces. Interviews and record review indicate that since C2 was admitted on 07/15/2025, there have been no reported incidents of C2 hitting staff or throwing feces at staff.

LPA’s interview with seven (7) staff members reflected that Six (6) staff have never observed C2 hit staff or throw feces. One (1) staff member reported they have not personally observed C2 hitting staff or throwing feces but stated they heard this information during a discussion with management regarding potential behaviors when C2 was first admitted to the facility. LPA’s interview with the Administrator revealed that when a new client is scheduled for admission, a meeting is held with staff within one week of the admission date to review the client’s plan of care and discuss any potential behaviors. Regarding C2, the Administrator stated they had previously worked with C2 at another location and had never observed C2 hit staff or throw feces at that location. The Administrator also stated that no staff have reported concerns to them regarding C2 residing at the facility. During LPA's records review of C2’s file, LPA did not observe any prohibited health conditions listed that would indicate C2 could not be admitted or retained in this facility.

Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “"Facility unable to meet the needs of a client in care"” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.