Complaint Investigation Report

The investigation revealed the following:

Allegation: Facility staff are physically abusive to resident.

The detail of complaint alleges that staff are physically abusive to C1. It is alleged that “staff threw C1 against the wall which left a hole in the wall.”

On 10/15/25, the Department interviewed Administrator (A1) via telephone. Who denied allegation stating that there were no reports of C1 being hit or pushed. A1 stated that all staff are Crisis Prevention Institute (CPI) certified and have had client’s rights training.

On 10/15/25, the Department interviewed 2 staff (S1-S2) regarding the allegation. 2 out of 2 denied the allegation stating that they have never hit or pushed a client nor have they witnessed any other staff hit or push a client. Lastly, 2 out of 2 staff stated that they are certified in CPI and know how to use de-escalation techniques when a client is having a behavior.

On 10/15/25, the Department interviewed 3 clients (C1-C3). 3 out of 3 stated that they feel safe in the home and that staff "treat them good.” 2 out of 3 stated that staff has never hit or pushed them, however, 1 out of 3 stated he was hit, but it was a long time ago, and the staff “quit a long time ago."

On 10/15/25, the Department obtained, reviewed, and evaluated the following pertinent documents: C1's Physicians report (dated 9/5/25), C1's Individual Program Plan (dated 1/9/25), Staff training: CPI (dated 8/20/24).