Complaint Investigation Report

and free of noise and others. Per review of C2's Individual Behavior Support Plan dated 9/5/2024 C2's primary objective is to reduce physical aggressive behavior to 0 times per month across 6 consecutive months, C2 also has two staff members assigned to them. Per Individualized Program Plan (IPP) dated 3/7/2025 C2's behaviors were focused on ways for C2 to remain in optimal mental and physical health; with the help of the facility and medical team.

On 9/29/25 both C1 and C2 approached the kitchen trash can from different directions. One assigned staff member for C1, was cooking breakfast and it is unclear where the second assigned staff member to C1 was located. C2 was also approaching the trash can and also has two staff members assigned to them. One of C2's assigned staff members, immediately stood between the two clients as they met at the kitchen trash can. C1 was able to reach around the staff member between them and struck C2. C2 immediately tried to retaliate and staff members attempted to restrain C2 with a CPI hold A second team hold was initiated with C2 and two staff members for C1 immediately left the area, went outside through the backyard and waited with a third client, and staff members, in the garage. Staff and clients returned indoors when C2 left the facility on a walk with two staff members.

LPA interviewed three of three clients. Two of the three clients confirmed staff did not prevent the incident from occurring. Three of three staff were interviewed and also confirmed the incident could have been avoided. One of one witness was interviewed and was present but was tasked with making breakfast. The witness immediately went to assist during the incident and took C1 outdoors and to the garage.

Based on LPA's record review, observations and interviews, the preponderance of evidence standard has been met, therefore the allegation that Staff did not prevent a resident from physically assaulting another resident in care is Substantiated.

An exit interview was conducted with Christina Mance, Regional Director of Operations and a copy of this report, LIC 811, LIC 9099-D and Appeal Rights were provided to the facility.