Complaint Investigation Report

W1 reported that R1 has not been transported to medical appointments by the facility, citing behavioral concerns. W1 stated that “for two years, the facility hasn’t provided basic medical transport for R1,” adding that “his family has to take him, or he simply doesn’t go.” W1 also stated that the home issued a 30-day termination notice in 2024 but continued to limit R1’s activities even prior to that, including not supporting doctor visits. S1 reported, “Due to behavioral escalations during attempted outings, we consulted with R1’s conservator and arranged in-home medical visits as an alternative. S1 added “we’re modifying for safety of the resident.” S2 added, “CABA is here daily to provide essential support, and staff are trained to de-escalate, but the environment has to be controlled for the safety of the R1 and residents. We’re not equipped for unpredictable outings without jeopardizing safety.” S4 stated, “in coordination with CABA we are taking necessary steps for outings and different activity plans. LPA checked the weekly activity plan written on the board. S1 added, We’re now reassessing the behavioral plan, and CABA is working with us everyday to try again safely.”

LPA also reviewed MARs and noted no missed medications or irregularities. In-home physician note and visit summaries were present in R1’s file. Behavior data logs also showed incidents tied to off-site outings.

Allegation: Staff did not follow resident’s Needs and Services Plan - Unsubstantiated

W1 stated that staff did not follow R1’s Needs and Services Plan, specifically in implementing behavioral recommendations from CABA. According to W1, “Even with 2:1 staffing and outside behavior consultants, the facility has not made enough efforts to follow through on those plans.S2 stated, “The plan is reviewed every 30 days with behavior support input and CABA. "The team makes changes based on triggers we observe". S1 stated "R1's safety is the priority of the team.” S1 added, “We've documented every step. Sometimes we can only work on walking around the house, but we with coordination with CABA update the daily schedule based on the behavioral plan recommended by CABA.” S5 confirmed that “while the team hasn't been able to implement everything, they’ve been open and communicative". S4 stated that Facility staff meet with CABA staff several times per week to coordinate the activities. LPA reviewed meeting logs.

LPA reviewed R1’s Needs and Services Plan, including amendments dated March, May, and July 2025. LPA also reviewed CABA notes, reviewed weekly and daily schedule for R1. Communication logs showed coordination with CABA, and incident logs corresponded with adjustments in behavior plan.