Complaint Investigation Report

Allegation: Staff physically abused resident

Based on interview with S1, it was revealed that C1 does not have a cut over C1’s eye. S1 stated C1 suffers from Self-Injurious Behavior (SIB) but hasn’t had SIB in over a year. S1 stated C1 did have a cut over C1’s left eyebrow back in January 2022, as a result of SIB. Based on record review, it was revealed that C1 does have episodes of SIBs such as picking or scratching at himself repeatedly for more than 5 seconds or picks and scratches himself that result in bleeding.

Allegation: Staff neglect resulting in resident developing a pressure injury

Based on interview with S1 and S2, it was revealed that on August 8, 2025, C2 was transported to the hospital for evaluation due to lack of eating and abnormal bowel. S1 stated that on September 01.2025, C2 returned to facility with a pressure injury on buttock. S1 stated C2 returned to the facility with Home Health (HH) nurse once a week. Based on record review, it was revealed, C2 returned from the hospital with HH, HH care notes dated September 2, 2025, revealed C2’s skin is intact, and no redness.

Allegation: Facility is operating out of ratio

Based on interviews with S1, it was revealed that there are five staff members including lead staff scheduled on the AM and PM shift, and there are three staff members including lead staff on the NOC shift. Based on record review, it was revealed that all of the clients has client’s to staff ratio: C1 has 2:1, C2 has 1:1 and C3 has 1:1, record review also revealed facility is scheduling adequ ate staffing to support the client’s needs.