Complaint Investigation Report

It was also alleged that Client 2 (C2) exhibited abusive behavior toward staff and that the facility failed to adequately address the needs of C1 and C2 by not maintaining current and accurate records and care plans. LPA conducted interviews and reviewed facility records. Records and interviews confirmed that C1 experienced falls on 09/01/2025 and 09/10/2025.

On 09/01/2025, C1 was in the kitchen placing a dish in the dishwasher when they reportedly lost their balance and fell backward, striking their head on the counter behind them. Staff immediately responded to assist C1 and assess their condition. Staff contacted 911 and notified the Administrator. Paramedics arrived and transported C1 to a local hospital for evaluation. C1 was discharged the same day. Hospital discharge documentation reviewed by LPA did not indicate findings of a serious head injury.

On 09/10/2025, C1 informed staff that they had fallen in the restroom while opening the door to exit. Staff assessed C1, obtained vital signs, and observed that within approximately 15 minutes C1’s blood pressure increased from 139/122 to 143/135. Staff contacted 911 and paramedics transported C1 to a local hospital for further evaluation. C1 was discharged the same day. Hospital discharge documentation reviewed by LPA did not indicate findings of a serious head injury.

Interviews with seven (7) staff indicated that C1 has a history of behaviors that staff described as attention-seeking related to falls. Several staff reported observing situations in which C1 appeared to lower themselves to the floor, slowly slide out of a chair, or place objects in walking areas within their room that could create obstacles. Staff reported these behaviors have occurred on multiple occasions.

C1 relocated from the facility at the end of September 2025. C1’s most recent care plan, dated 02/06/2025, did not identify C1 as requiring one-to-one supervision or indicate that C1 was assessed as a fall risk. Facility staff reported that a new assessment had been planned; however, C1 was no longer residing at the facility at the time the reassessment was to occur.

Regarding the allegation that C2 exhibited aggressive behavior toward staff and that the facility did not adequately address this behavior, LPA reviewed C2’s records. Records reviewed included the Pre-Placement Behavioral Support Plan dated 07/14/2025, 30-Day Behavior Assessment and Individualized Service Plan dated 08/18/2025, Needs and Services Plan dated 09/06/2025, Individual Service Plan Quarterly Report dated 11/07/2025, and Physician’s Report dated 10/27/2025. These records documented identified behaviors including topic perseveration, verbal outbursts, self-injurious behavior, physical aggression, elopement, and non-compliance.