Complaint Investigation Report

interest in C1. Over time, C1 was transported from the facility to attend church or to go on other outings with the outside parties. Records maintained by the facility and reviewed during the investigation revealed that C1 has the ability to leave the facility on his/her own. Interviews conducted, including interview of C1, yielded that C1 has voluntarily chosen to go on outings with the outside parties.

In response to the report that C1 was not protected from being assaulted by another client in care, the investigation yielded that law enforcement was called and arrived at the facility on the morning of 5/1/2022, in response to an altercation in which C1 was attacked by C5. According to law enforcement records, C5’s attack on C1 was initiated because of C5’s diagnosed mental health issues. Records reflect that no injuries were sustained by C1. Records also reflect that C5 had been administered prescribed medications the morning of the incident. C5 was taken into custody and taken to a local hospital for mental health services. The investigation yielded no subsequent incidents following C5’s discharge from the hospital and return to the facility. There was no evidence obtained to conclude that C5’s attack resulted from action or lack of action on the part of facility staff.

The second allegation is that C1’s personal property was not safeguarded. Records reviewed during the investigation reflected that clients were provided notification that the licensee, administrator, and staff would not be responsible for valuables and personal property brought into the facility, unless the items were given to the licensee or administrator for safeguarding. It was further discovered, through outside source interview, that C1 was informed, during the admission process, that there would be very limited storage space available and that items of personal value should not be kept in the open. In addition to the foregoing, the investigation did not produce evidence to corroborate that items were missing or taken from C1.

The third allegation is that client’s room did not have heat. It was reported that the heater in C1’s room did not work. During a visit to the facility, a tour of the facility revealed that some client rooms within the facility did not have heat, including the room in which C1 was initially placed at the time of admission. However, it was observed, and interviews yielded that facility staff provided portable heaters and/or blankets to clients, upon request, or when staff were made aware that a client did not have sufficient heat. The investigation also yielded that C1 was provided a portable heater for use, once facility staff were made aware of C1’s discomfort.