Complaint Investigation Report

The investigation revealed the following: Regarding the allegation: Staff did not report incident (s) to residents' responsible party . It’s being alleged that restraints were used by staff on 02/02/2024, 02/27/2024, and 06/03/2024 and the incident reports were not submitted to the appropriate agencies. LPA Spaeth observed Community Care Licensing (CCL) received the LIC624 reports for the 02/02/2024 and 02/27/2024 incidents in a timely manner. LPA observed the Administrator’s copies of the report which included fax confirmations to CCL. However, LPA observed CCL did not receive the 06/03/2024 LIC624 report. The Administrator provided a copy of LIC624 dated 6/03/2024 report but the Administrator could not provide a fax confirmation.

Regarding the allegation, Staff do not have the proper training . It’s being alleged that staff member (S1) had not completed the annual sixteen hour emergency intervention training. LPA Spaeth observed S1’s training certificate dated 6/20/2023. The certificate states continued certification requires an annual re-certification. The Administrator explained there was a ninety day grace period allowed by the training company. The Administrator was under the impression there was adequate time for S1 to complete the training. Therefore, S1 did not complete the required training by 6/20/2024. The Administrator provided documentation from the training company stating S1 completed the training on 9/04/2024.

Based on interviews and record review, the allegations are substantiated. See 9099D for details.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.