Complaint Investigation Report

The investigation revealed the following: Regarding the allegation “Staff did not follow reporting requirements,” it was reported that on 08/05/25, during assisted ADLs, a client (C3) was transferred onto a shower bed that broke, requiring assistance to the floor by 2 staff. The incident was not reported to CCL. On 09/28/25, a client (C1) fell, requiring assistance to the floor. The incident was not reported to CCL. LPA interviewed three (3) staff (S1-S3). 2 out of 3 staff interviewed were not aware of the incidents. S1 stated that on 09/28/25 a temporary care plan had been put in place for C1 due to an “assisted” fall. LPA reviewed facility Incident Reporting policy which indicated any fall must be reported. LPA reviewed CCL’s folder for special incidents reports (SIRs) submitted by the facility and observed SIRs were not submitted to CCL. Staff was not able to provide documentation of the above mentioned incidents being reported to CCL as special incident reports. Deficiency cited and civil penalties are being issued for a repeat violation.

Regarding the allegation “Staff file is incomplete,” it was reported that staff files had no documentation for in-service training November 2025 and December 2025. 3 out of 3 staff interviewed stated they receive monthly on-the-job training. In-service training are 1 to 2 hours and cover various topics including policies and procedures, medication, charting, and client care. LPA reviewed facility file which contained a monthly schedule for in-service training, logs signed by staff in attendance, and included documentation of topics covered. There was no documentation for in-service trainings conducted August 2025 and November 2025. Staff was not able to provide documentation for trainings conducted August 2025 and November 2025. Deficiency cited.

Regarding the allegation “Staff did not ensure medication was given as prescribed,” it was reported that on 09/12/25, a client (C1) did not receive a prescribed nebulizer treatment. LPA reviewed MAR (medication administration records) logs for C1 dated 09/12/15. MAR log for C1 was not initialed for PM administration of nebulizer treatment administration. Staff was not able to confirm PM nebulizer treatment was administered for C1. Deficiency cited.