Complaint Investigation Report

Regarding the allegation that facility staff are not properly storing food: it was alleged that a bag of snacks was left opened and not sealed in the kitchen cabinet and leftover food was wrapped in a paper towel in the kitchen refrigerator. LPA inspected the facility, conducted health and safety checks on the clients, observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required, and noted that expiration dates were marked and there were no expired foods. However, LPA also observed a bag of cookies left open in the kitchen pantry and a jar of food not properly sealed in the kitchen refrigerator. LPA interviewed PM who admitted the allegation, stated they had already conducted some staff training on food storage, and stated they will conduct additional training on food storage. LPA interviewed two clients and did not obtain information about any additional food concerns at the facility. The information obtained corroborated the allegation.

Regarding the allegation that facility staff are not properly trained: it was alleged that multiple staff did not have documentation of required annual training and that staff did not have required inhaler training. LPA interviewed PM who denied the allegation. LPA reviewed the staff training records for six staff and confirmed they all have documentation of required training. However, PM admitted that there is a restricted health condition care plan for a client with an inhaler and that not all staff were trained on the restricted health condition. LPA reviewed staff training records and the facility’s staff schedule and noted that on February 4, 5, and 6, 2025, during the overnight shift, there was no staff on duty who had completed the inhaler training. The information obtained corroborated the allegation.

Regarding the allegation that facility staff did not ensure clients received medical services: it was alleged that clients did not receive the recommended number of consultation hours from medical providers. LPA interviewed two clients who did not raise concerns regarding the outside medical services they are receiving. LPA interviewed PM who admitted the allegation, stating that both clients have not received the required number of hours from their medical consultants. LPA reviewed C1’s Service Plan, which states C1 should be getting four hours of psychiatric services per month, but C1’s Consultant Log shows C1 only received three and a half hours of psychiatric services in February 2025. LPA reviewed C2’s Service Plan, which states C2 should be getting one hour of primary care services per month, but C2’s Consultation Log shows C2 did not receive any hours of primary care services between October 2024 and January 2025. The information obtained corroborated the allegation.