Complaint·May 7, 2026

An LPA’s records review confirmed that R1 and R2 had one same prescribed medication. Based on interviews conducted and records review, the Department’s investigation provided enough information to corroborate the allegation that staff mismanaged residents’ medications. This allegation is substantiated. It was alleged that staff did not comply with reporting requirements. Information received indicated that staff did not inform R1’s responsible person when the medication error occurred. LPA conducted an interview with R1’s relevant party, who stated that staff never informed about the medication incident. LPA’s records review revealed that staff had not reported the medication error to the Department. Based on interviews conducted and records review, the Department’s investigation provided enough information to corroborate the allegation that staff did not comply with reporting requirements. This allegation is substantiated. It was alleged that staff did not ensure hazardous items were inaccessible to residents. Information received indicated that Resident #3 (R3) took a knife from the facility kitchen while the door remained open. LPA’s record review revealed that R3 followed a staff member into the facility kitchen and took a knife on 07-21-2024. R3 waved the knife around and chased one of the staff members. 911 was called and R3 was placed under frequent check. Based on records review, the Department’s investigation provided enough information to corroborate the allegation that staff did not ensure hazardous items were inaccessible to residents. This allegation is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was provided, along with LIC9099-D, and Appeal Rights. LPA obtained and reviewed pest control reports and invoices from June 2024 through August 2024 and observed that staff hired pest control company and treated all buildings in the facility every month. LPA toured the interior and exterior of the facility and did not observe any signs of pest infestation. Based on records review and observations, the Department’s investigation did not provide enough information to corroborate the allegation that staff are not properly addressing pest infestation in facility. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.