complaint·December 10, 2025

Report Continued from LIC 9099... It was alleged that staff did not ensure medication was inaccessible to resident. It was reported that Resident #1 (R1) had taken THC gummies that were allegedly left in their room due to staff not properly cleaning the room. Record review and interviews conducted revealed that R1 was taken to the hospital on 10/02/2025 after feeling dizzy and weak. According to the incident report, R1 was transported to the hospital after care staff called 911. R1 returned to the facility the same day with a diagnosis of syncope. Interviews with staff indicated that all medications are kept in locked medication carts located inside the medication room. Staff stated that the medication room remains locked at all times when medications are not being administered or when staff are not present. Staff also reported that they assist residents with maintaining clean bedrooms and denied observing medications in any resident’s room. Interviews with R1’s family revealed that the facility communicates well with them regarding R1’s condition and needs. They stated that they had no concerns about R1 receiving the correct medications when ordered by a physician, noting that R1 was not on any medications until recently. Furthermore, during an interview, R1 denied eating any candy or taking any gummies. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not ensure medication was inaccessible to resident”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff spoke inappropriately to resident in care. It was reported that staff were observed being mean and yelling at Resident #2 (R2), telling R2 to stop crying. Interviews conducted with staff revealed that R2 often asks to speak with a specific family member. Staff stated that although they attempt to redirect R2, they sometimes call R2’s family to help calm R2. Staff added that R2’s family has stated they do not mind being contacted, as they want to ensure R2 is safe. Further staff interviews indicated that they have not observed other staff members disrespecting residents and denied ever having disrespected residents themselves while working and providing care. During interviews with R2’s family, they stated that facility staff are great and patient with R2 and expressed no concerns regarding how staff treat R2. Interviews with other residents’ family members revealed that they have not witnessed staff mistreating residents during their visits. Additionally, family members did not report any concerns about facility staff or the way residents are treated, stating that staff have been wonderful to both residents and visitors. Based on interviews, the Department has insufficient evidence to support the allegation of “staff spoke inappropriately to resident in care”. Therefore, this allegation is deemed Unsubstituted at this time. Exit interview conducted. A copy of the report was issued.