Sola Thurston

The provider used an unauthorized physical restraint on a client, causing distress and placing the client at risk of compressive asphyxia.

Provider used an unauthorized physical restraint on a client, resulting in distress and potential risk of compressive asphyxia.

Provider failed to immediately report suspected abuse of a vulnerable adult, delaying investigation.

Provider failed to follow the Positive Behavior Support Plan (PBSP) and instead used unapproved items (mattress topper) and body weight to restrain the client.

Provider failed to implement and train staff on policies regarding client rights, reporting abuse, and the appropriate use of restrictive interventions.

The provider failed to provide adequate staffing for Client 1 during the night shift (10PM-6AM), despite the client requiring two-person assists for transfers.

The provider failed to revise and update the Person Centered Service Plan (PCSP) for Client 1 to reflect their new medical needs and hospice status in a timely manner.

Failed to document completion of required continuing education (CE) for two staff members.

Failed to ensure equitable sharing and reconciliation of household expenses for two clients.

Provider failed to complete a required Character, Suitability, and Competence Review (CSCR) for one staff member following a new background check.

Failed to provide written instructions to staff regarding the safe use of medical devices (wheelchair and shower chair seatbelts/straps) for two clients.

Client 6 had a chime installed on their bedroom window without a documented plan or agreement by the legal representative.

Failed to reconcile and/or verify provider-managed client accounts for four clients.

Provider failed to provide necessary safety measures for the client, resulting in frequent, inappropriate use of emergency medical services (EMS) for non-injury falls.

Provider failed to notify the department when client's service needs changed and the person-centered service plan no longer met their needs.

Provider failed to correctly administer medication and failed to report medication errors to the Complaint Resolution Unit (CRU) as required by policy.