Complaint Investigation Report

It was reported that "staff retaliated against resident for filing a complaint" as it was alleged that Staff #1 (S1) made up a story that S1 dodged an attempted strike from Client #1 (C1) after a complaint was filed that involved C1. Interviews conducted and records reviewed reflected that on 09/26/2025, the Regional Office reviewed a self-reported incident report (SIR) dated 09/25/2025 that stated at approx. 07:30 a.m. C1 was encouraged to carry out daily living activities to prepare for day program. After 20 minutes, staff encouraged C1 again, which led to an emotional outburst. C1 began yelling at staff and attempted to hit S1, but C1 missed. S1 encouraged C1 to remain calm, which C1 eventually did then they continued to their day program. Interviews conducted with S1, three (3) staff members and two (2) residents who witnessed the incident confirmed that an altercation occurred. LPA’s interview with C1 revealed they do not recall the incident and reported no concerns regarding staff in the home at this time. Additional Interviews with three (3) clients revealed they had no concerns regarding staff at this time. LPA also interviewed three (3) family members/responsible parties of clients in care, all of whom stated they had no concerns regarding possible staff retaliation against clients at this time. LPA's interviews with Behaviorist for the home and Tri-county Service Coordinator for the home revealed they each had no concerns regarding possible staff retaliation against clients 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 retaliated against resident for filing a complaint” is deemed Unsubstantiated at this time.

It was reported that "Staff mismanaged resident's medication" as it was alleged that Administrator improperly managed C1's medications by repeatedly administering lorazepam and staff threatened to not assist C1 with medication administration. Interviews conducted and records review revealed C1's medication of Lorazepam 1 MG Tabs, take 1 tablet by mouth daily as needed for Severe anxiety was discontinued on 10/07/2025.

LPA’s review of Medication Administration Records (MARs) from October 2025 through January 2026 revealed that Lorazepam was not administered to C1 during that time. Although C1’s primary care provider issued a discontinuation order, the pharmacy continued delivering the medication to the facility through January 2026. Facility staff returned the medication to the pharmacy, and LPA observed records of unused bubble packs for C1 dated November 2025 through December 2025. On 03/20/2026, it was additionally alleged that staff threatened to withhold C1’s medication if they acted inappropriately. Interviews conducted with six (6) staff members revealed all denied refusing to assist clients with medication administration or observing any staff deny medications to residents in care. During an interview with LPA, C1 stated they did not recall any staff informing them that medication would be withheld.