Complaint Investigation Report

During todays visit, LPA interviewed the Administrator and a total of 4 staff who shall be referred to as staff#1 through staff #4 (S1-S4). LPA also interviewed at total of 3 clients, who shall be referred to as Client#1 through Client#3 (C1-C3). LPA interviewed C1’s service coordinator, who shall be referred to as Witness#1 (W1). LPA obtained staff trainings, Record of clients/Residents safeguarded cash resources for C2 and C3 (C1 is not receiving P&I), 1 month of client notes, and all clients Individual Program Plan (IPP).

The investigation reveals the following: Regarding “Resident sustained multiple injuries due to staff neglect”. It is alleged that C1 has suffered some bruises on legs from dropping to the ground and from staff trying to pick C1 up. The Administrator denied the allegation stating the clients have a ratio of 1:3, 1:4, and 1:2. The Administrator further stated staff do not physically touch clients during behaviors, unless they are a danger to themselves or others. Whenever C1 drops to the floor, staff uses methods such as laying down a blanket or pillow to help prevent injuries. 4 out of 4 staff denied the allegations stating they have never neglected C1 during their behaviors. Staff further stated they have used pillows, yoga matts, and blankets to keep C1 from harming themselves. 3 out of 3 clients denied the allegation, stating that staff have never hurt them physically. W1 confirmed C1 has behaviors and is on a 1:3 ratio with practically 24-hour care. LPA reviewed C1’s IPP and observed the client has a history of self-injurious behaviors.

The investigation reveals the following: Regarding “Staff handled resident in a rough manner”. It is alleged that staff fling C1. The Administrator denied the allegation stating staff do not physically touch clients during behaviors unless they are a danger to themselves or others. The administrator further stated they have never treated the clients roughly. 4 out of 4 staff denied the allegations stating they have never witness staff treating the clients in a rough manner. 3 out of 3 clients denied the allegation, stating that staff have never hurt or abused them. W1 confirmed that staff have never abuse C1 and they conduct monthly visitation.

The investigation reveals the following: Regarding “Staff threatened resident”. It is alleged that staff threaten C1 with sleeping on the floor if C1 do not put on Pajamas. The Administrator denied the allegation stating staff has never threaten the clients. 4 out of 4 staff denied the allegations stating they have never witness staff threatening the clients. 3 out of 3 clients denied the allegation stating staff has never threaten them. W1 confirmed that staff have never threaten their client and they conduct monthly visitation.

The investigation reveals the following: Regarding “Staff are not properly trained”. It is alleged that some staff are not properly trained. The Administrator denied the allegation stating staff are trained by the facility and behaviorist frequently. 4 out of 4 staff denied the allegation stating they are properly trained. LPA reviewed training for all staff interviewed and confirmed all trainings including the initial 40 hours, continuing education, and valid CPI cards.

The investigation reveals the following: Regarding “Staff did not safeguard resident's personal belongings”. It is alleged that staff snatch a phone number from C2. The Administrator denied knowledge of the incident and stated there is no issues regarding the client’s personal belongings. 4 out of 4 staff denied knowledge of the incident and further stated there is no issues of theft in the home. 3 out of 3 clients denied the allegation and knowledge of the incident. During the tour LPA observed each client’s room is decorated to their preferences. Report continued on 9099c