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32 | The investigation revealed the following: regarding the allegation “Staff are not providing a safe environment for clients in care.” It is alleged staff are not providing a safe environment for clients in care. One (1) out of the two (2) clients interviewed denied this allegation. Due to cognitive impairments, C2’s interview was unreliable and therefore documented as an attempted interview. LPA made multiple attempts to contact C3 via phone, but all attempts were unsuccessful. LPA attempted to interview C3 in person on 02/10/2026 and 04/18/2026 but all attempts were unsuccessful. According to staff, C3 frequently stays with family during the week and on weekends. Three (3) out of the three (3) staff interviewed denied this allegation. Interview with S2 revealed that C1 and C4 do get into verbal arguments but staff intervene and redirect both clients back to their baseline. Interview with S4 revealed that C1 has contacted local police when C4 yells at C1 but by the time police arrive, staff have already redirected C4 away from C1 and have defused the situation. During record review, LPA observed emails dated (1/30/2026) from Administrator Jasmin Tomines to C4’s placement agency and C4’s family, advising them of increased aggressive behaviors towards clients and staff, despite staff’s efforts to counsel C4 and provide redirection. Administrator Tomines advised C4’s placement agency that C4’s psychiatric doctor recommended increasing C4’s medication of Uzedy, from 100mg to 150mg monthly. Administrator Tomines requested authorization from C4’s placement agency to make changes to C4’s medication. Review of C4’s medication administration record (MAR) revealed that C4’s medication was adjusted and is being administered according to C4’s physician’s orders. Interview with S1, S2 and S4 revealed that since C4’s medication was adjusted, C4’s behaviors have decreased. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
No deficiencies were cited. Exit interview was conducted. A copy of this report was provided.
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