Inspection Reports for The Views of Cedar Rapids | RidgeView Assisted Living
IA, 52405
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 24, 2024, identified deficiencies related to dietary sanitation, medication management including insulin labeling and administration, and incomplete tenant evaluations and service plans. Earlier inspections showed a pattern of similar issues with medication management, service plan updates, and staff training, although some complaint investigations found no deficiencies. Prior reports also noted deficiencies in background checks, staffing training, and food service sanitation, but enforcement actions such as fines were only listed in a 2010 complaint investigation, which included a $1,500 civil penalty. Most complaint investigations were unsubstantiated, with the exception of medication-related issues and documentation concerns in several earlier reports. The facility’s inspection history shows recurring challenges in medication management and service planning, with no clear trend of consistent improvement or worsening over time.
Deficiencies (last 15 years)
Deficiencies (over 15 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
27 residents
Based on a October 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 5
Date: Oct 24, 2024
Visit Reason
The inspection was conducted as part of the investigation of Complaint #121431-C and the recertification visit to determine compliance with certification of an Assisted Living Program.
Complaint Details
The visit was complaint-related, investigating Complaint #121431-C. The complaint involved issues with dietary sanitation and medication management policies.
Findings
The program failed to follow dietary sanitation policies and medication management policies, including improper labeling and administration of insulin. Additionally, evaluations and service plans were not completed within required timeframes for some tenants, and nurse reviews were not conducted following significant changes in tenant health status.
Deficiencies (5)
Failure to follow dietary sanitation policy; no cleaning checklists completed in the kitchen area.
Failure to follow medication management policy regarding insulin administration and labeling for two tenants.
Failure to complete tenant evaluations within 30 days of occupancy for one tenant.
Failure to update service plans within 30 days of occupancy for one tenant.
Failure to complete nurse reviews after significant changes in health status for two tenants.
Report Facts
Total census: 27
Tenants without cognitive impairment: 24
Tenants with cognitive impairment: 3
Insulin expiration days: 28
INR value: 5.8
INR value: 4.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed medication and evaluation deficiencies and provided statements regarding required documentation and policies. |
| Dietary Manager | Dietary Manager | Confirmed dietary staff did not complete cleaning checklists and provided information about sanitation policies. |
| Medication Manager | Medication Manager | Administered medications and provided information about insulin administration and labeling. |
| Consultant Registered Dietician | Consultant Registered Dietician | Confirmed dietary sanitation policy non-compliance. |
| Consultant Nurse | Consultant Nurse | Verified nurse review documentation was required for significant health changes. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
Investigation into Complaint #111245-C at Ridgeview Assisted Living.
Complaint Details
Investigation into Complaint #111245-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Inspection Report
Renewal
Census: 31
Deficiencies: 1
Date: Dec 12, 2022
Visit Reason
The recertification visit was conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
The program failed to complete background checks prior to hire for 2 of 7 employees reviewed. Specifically, background checks for Staff D and Staff G were completed after their hire dates.
Deficiencies (1)
Failed to complete background checks prior to hire for 2 of 7 employees reviewed (Staff D and Staff G).
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 3
Total census: 31
Employees reviewed: 7
Employees with late background checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in deficiency for late background check | |
| Staff G | Named in deficiency for late background check | |
| Philip Maxey | Director | Signed Plan of Correction |
Inspection Report
Renewal
Census: 33
Deficiencies: 0
Date: Sep 1, 2020
Visit Reason
Recertification visit conducted to determine compliance with certification for an Assisted Living Program and the onsite infection control survey.
Findings
No regulatory insufficiencies were cited during the recertification visit or the onsite infection control survey.
Inspection Report
Renewal
Census: 29
Deficiencies: 1
Date: Mar 22, 2018
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification rules for an Assisted Living Program (ALP).
Findings
The program failed to meet staffing requirements as the newly hired Registered Nurse did not ensure that certified and noncertified staff were sufficiently trained within 60 days of employment. Specifically, 2 of 4 staff reviewed were not properly trained or documented within the required timeframe.
Deficiencies (1)
Staffing: The program's newly hired registered nurse failed to ensure certified and noncertified staff were competent to meet tenant needs within 60 days of employment.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Destiny Hellyer | Director | Signed the Plan of Correction letter dated April 6, 2018 |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 4
Date: Feb 1, 2017
Visit Reason
The inspection was conducted to investigate complaints #64403-C, #65568-C, #65583-C, and #65585-C regarding regulatory insufficiencies at Rosebush Gardens Assisted Living.
Complaint Details
Complaints #64403-C, #65568-C, #65583-C, and #65585-C were investigated during this visit.
Findings
The investigation identified deficiencies in staffing training documentation, nurse delegation procedures, medication administration, and service plans. Specific issues included lack of documented training on Bipap machines for staff, failure to provide services according to training, improper medication administration practices, and service plans not reflecting tenants' identified needs.
Deficiencies (4)
Program failed to maintain documentation of fire alarm training for 2 of 6 staff and training on a bilevel positive airway pressure (Bipap) machine for 4 of 4 direct care staff.
Program failed to ensure staff provided services in accordance with training for 4 of 5 tenants reviewed, including issues with oxygen and medication administration.
Program failed to ensure medication pass was completed in accordance with training, including timing and sanitization procedures.
Program failed to ensure service plans reflected identified needs for 2 of 5 tenants reviewed, including blood glucose checks, insulin administration, and use of Bipap machine.
Report Facts
Census: 27
Staff reviewed for fire alarm training: 6
Staff reviewed for Bipap training: 4
Tenants reviewed for service plan compliance: 5
Blood glucose checks per day: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Thoma | Director | Signed the Plan of Correction letter dated 2/21/17 |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Date: Apr 12, 2016
Visit Reason
The inspection was conducted as a Final Recertification Monitoring Evaluation and Complaint/Incident Investigation following a survey by the Department of Inspections and Appeals on April 12 & 13, 2016, triggered by complaint #58207-C and incident #59419-I.
Complaint Details
The complaint involved allegations that service plans were not reviewed or signed by tenants, and that staff smoked near the building causing smoke to drift inside. All allegations were found not substantiated after interviews and file reviews.
Findings
The investigation found that allegations related to tenant rights, service plans, and structure/life safety were not substantiated. However, regulatory insufficiencies were identified in the areas of written occupancy agreements and food service, requiring a Plan of Correction.
Deficiencies (3)
The program did not execute an occupancy agreement prior to tenant occupancy for multiple tenants.
The program failed to notify the Department regarding a dependent adult abuse report related to missing medications within 24 hours.
Personnel responsible for food preparation or service did not have orientation on sanitation and safe food handling or annual in-service training on food protection.
Report Facts
Census: 33
Tenants without cognitive disorder: 33
Tenants with cognitive disorder: 0
Date of survey: Apr 13, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jay W Henshaw | Director | Named as recipient of report and involved in interview regarding missing medications and smoking allegations |
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the report |
Inspection Report
Monitoring
Census: 31
Deficiencies: 0
Date: Sep 3, 2014
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted by the Department of Inspections and Appeals in accordance with Iowa Administrative Code chapters 481-67 and 481-69 to evaluate compliance and recertification of the Assisted Living Program at Rosebush Gardens.
Findings
No regulatory insufficiencies were found during this evaluation. The program met all requirements, and tenant satisfaction was positive with no deficiencies noted during the on-site investigation.
Report Facts
Total census of Assisted Living Program: 31
Number of tenants without cognitive disorder: 31
Number of tenants with cognitive disorder: 0
Tenant meeting attendance: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Schmidt | Administrator | Administrator of Rosebush Gardens Assisted Living |
| Wendy Kuhse | RN, BS | Monitor for the evaluation |
| Mike Rohner | OTR/L | Monitor for the evaluation |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 5
Date: Jun 5, 2013
Visit Reason
The inspection was conducted as a final complaint/incident investigation based on complaints regarding tenant deaths, tenant checks, short temper of the manager, and roof leaks with mold in the attic.
Complaint Details
Complaint/Incident Intake #43880-C involved concerns about tenant deaths and tenant checks. Complaint/Incident Intake #44124-C alleged the manager was short tempered and that the roof had leaked for years causing mold in the attic. The complaints were investigated with findings of regulatory insufficiencies but no substantiation status explicitly stated.
Findings
The investigation found regulatory insufficiencies related to policies and procedures for tenant death reporting, evaluation and service plans not updated as needed, medication administration issues, tenant rights concerns, and structural damage from a storm with failure to notify the department. Several tenant deaths were reviewed with findings of incomplete incident reports and safety checks.
Deficiencies (5)
Failure to follow policy and procedure regarding death of a tenant and incomplete incident reports for tenant deaths.
Service plans were not updated as needed and did not reflect identified needs of tenants.
Medication administration issues including lack of documentation and failure to notify doctor of abnormal blood glucose readings.
Failure to update service plans within required timeframes and to individualize plans as required.
Failure to notify the Department of damage sustained to the building during a storm as required by regulation.
Report Facts
Census: 32
Dates of Investigation: June 5, 12 and July 3, 2013
Tenant deaths reviewed: 2
Tenant ages: Tenant #1 (100 years), Tenant #2 (92 years), Tenant #3 (68 years), Tenant #4 (97 years), Tenant #5 (83 years)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Van Dolah | Manager | Named in complaint and investigation report |
| Stephanie Cummins | MA | Monitor for the investigation |
| Margaret Kaltefleiter | RN MS | Monitor for the investigation |
| James Berkley | RN BS, Program Coordinator | Monitor and contact person for the report |
| Staff #1 | Interviewed and involved in tenant care and maintenance issues | |
| Staff #2 | Interviewed and involved in tenant care | |
| Staff #3 | Involved in medication administration and tenant care | |
| Staff #4 | Maintenance staff | Interviewed regarding roof leaks and storm damage |
| Staff #5 | Mentioned in tenant care and incident reports | |
| Nurse | Involved in tenant care and incident reporting | |
| Manager | Mentioned in relation to tenant care and storm damage reporting |
Inspection Report
Renewal
Census: 29
Deficiencies: 1
Date: Nov 21, 2011
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation for Rosebush Gardens Assisted Living Program to review the Plan of Correction and ensure compliance with Iowa Code and Administrative Code requirements.
Findings
The report found that the Plan of Correction was accepted and the recertification documents were approved. The program did not receive any regulatory insufficiencies during this certification period. Tenant satisfaction was positive, and some minor food service training deficiencies were noted but addressed.
Deficiencies (1)
Personnel responsible for food preparation or service did not have orientation on sanitation and safe food handling prior to handling food and lacked annual in-service training on food protection.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 29
Number of tenants and family members at community meeting: 20
Dates of Assisted Living Program Certificate: Effective from March 26, 2012 through March 25, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Signed letter regarding certification |
| Stephanie Cummins | MA | Monitor for the evaluation visit |
| Margaret Kaitefleiter | RN MS | Monitor for the evaluation visit |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 10
Date: Apr 21, 2010
Visit Reason
A complaint investigation was conducted at Rosebush Gardens on April 21, 22, 27 & 28, 2010, to investigate allegations including falsified assessments, inappropriate tenant care, service plan falsifications, medication administration issues, staff training deficiencies, and administrative staff misconduct.
Complaint Details
The complaint investigation addressed allegations of falsified assessments, inappropriate tenant care including wandering and incontinence, service plan falsifications, medication administration delays, staff training deficiencies, call light malfunctions, leaking windows, snow removal issues, mail mishandling, staff selling prescription drugs, tenant money missing, and intimidation by administrative staff. Most allegations were unsubstantiated or not supported by evidence. No retaliation towards tenants was found.
Findings
The investigation found no evidence of falsified records or service plans, but identified regulatory insufficiencies related to tenant evaluations, service plan updates, nurse reviews, medication administration documentation, staff training, and administrative practices. Several complaints were unsubstantiated, and no retaliation towards tenants was found. A $1,500 civil penalty was assessed.
Deficiencies (10)
Regulatory insufficiency in evaluation of tenants, service plans, and staffing.
Regulatory insufficiency: A program shall evaluate each tenant’s functional, cognitive and health status within 30 days of occupancy and annually thereafter.
Regulatory insufficiency: Service plans must be updated within 30 days of tenant’s occupancy or significant change and be individualized.
Regulatory insufficiency: Medication administration was generally timely but documentation was incomplete or missing for multiple medications.
Regulatory insufficiency: Nurse reviews were not completed by an RN as required and lacked documentation.
Regulatory insufficiency: Staff training on nurse delegation tasks and oxygen administration was incomplete or undocumented.
Regulatory insufficiency: Call lights functioned properly and were checked regularly.
Regulatory insufficiency: No issues with windows, leaks, or electrical outlets were found.
Regulatory insufficiency: No snow removal issues or tenant mail mishandling were substantiated.
Regulatory insufficiency: No retaliation or intimidation towards tenants or staff was found.
Report Facts
Civil penalty amount: 1500
Complaint intake numbers: 27914-C and 28353-C
Tenant census: 36
Investigation dates: April 21, 22, 27 & 28, 2010
Fine payment deadline: 30
Civil penalty reduced amount: 975
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Van Dolah | Manager | Named as facility manager and involved in interview and statements |
| Tamara Halvorson | Certification Coordinator | Contact for civil penalty payment and appeals |
| Hal L. Chase | RN BSN MPH | Monitor for complaint investigation |
| Stephanie Cummins | MA | Monitor for complaint investigation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed conclusion letter |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 4
Date: Jan 13, 2010
Visit Reason
The inspection was conducted as a complaint investigation and recertification monitoring evaluation at Rosebush Gardens, Burlington, IA, triggered by a complaint regarding the program's driveway and parking lot conditions.
Complaint Details
The complaint alleged that the program's driveway and parking lot contained packed snow and ice, causing difficulty walking. The investigation found the parking lot and sidewalks were mostly clear with minimal snow. A fall incident on 12-11-09 involving Tenant #1 was reported, resulting in a left ankle fracture/dislocation. The program reported the incident to the Department. No regulatory insufficiencies were substantiated related to the complaint.
Findings
The investigation found no substantiated regulatory insufficiencies. The parking lot and sidewalks were generally clear of snow and ice with minimal residual snow. A fall incident involving Tenant #1 was reported and investigated, but no regulatory insufficiencies were noted. Staff training deficiencies were identified but not classified as regulatory insufficiencies.
Deficiencies (4)
Cognitive evaluations for tenants were not completed annually or within 30 days of occupancy as required.
Service plans were developed but not based on cognitive evaluations as required.
Staff files lacked documented training on activities of daily living and nurse delegation training was incomplete or not done by registered nurses.
A sufficient number of trained staff were not always available to meet tenants' identified needs.
Report Facts
Current number of tenants without cognitive disorder: 39
Current number of tenants with cognitive disorder: 0
Total population: 39
Number of tenants in community meeting: 19
Complaint Intake Number: 26790
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the complaint investigation and monitoring evaluation |
| Chris Nothaft | Certification Coordinator – Eastern Iowa | Signed the final recertification monitoring evaluation report letter |
Inspection Report
Monitoring
Census: 39
Deficiencies: 4
Date: Apr 2, 2008
Visit Reason
The visit was a recertification monitoring evaluation conducted to review the facility's compliance with regulatory requirements and the Plan of Correction submitted in response to identified regulatory insufficiencies.
Findings
The evaluation found multiple regulatory insufficiencies related to the program's failure to consistently evaluate tenants' functional, cognitive, and health status prior to and within 30 days of occupancy, and deficiencies in individualized service plan development. There were no substantiated regulatory insufficiencies during this certification period starting March 26, 2008.
Deficiencies (4)
The program did not consistently evaluate each proposed tenant's functional status prior to signing the occupancy agreement and taking occupancy.
The program did not consistently evaluate each tenant's functional, cognitive, and health status within 30 days of occupancy and as needed.
The program did not develop a service plan for each tenant based on evaluations conducted.
The program did not individualize the tenant's service plan or indicate the tenant's identified needs and requests for assistance and expected outcomes.
Report Facts
Tenants without cognitive disorder: 39
Tenants with cognitive disorder: 0
Total population: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the evaluation |
| Kirk Erickson | Administrator | Administrator of Rosebush Gardens Assisted Living |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Jul 2, 2007
Visit Reason
A complaint investigation on-site visit was conducted at Rosebush Gardens to investigate multiple allegations including improper notification of room rate increases, tenant care concerns, destruction of records, and staffing issues.
Complaint Details
The complaint investigation was triggered by allegations including improper notification of room rate increases, tenant exceeding level of care, destruction of records, inaccurate service plans, medication order transcription errors, unauthorized menu changes, failure to provide special diets, missed meals due to lack of assistance, staff dishonesty, inadequate staffing, improper handling of colostomy care, forced showers, lying to tenants, and unsafe facility conditions. Most allegations were found unsubstantiated except for service plan and physician order documentation deficiencies.
Findings
The investigation found no regulatory insufficiencies for most allegations, except for deficiencies related to service plans not being consistently developed or updated within 30 days of occupancy or with changes in condition, and physician orders not documented with time, date, and signature. All other complaints were unsubstantiated.
Deficiencies (2)
The program did not consistently develop service plans within 30 days of occupancy and, as needed, with a change in condition and that reflect the identified needs of the tenants.
The program did not document physician orders with time, date and signature.
Report Facts
Current number of tenants without cognitive disorder: 40
Current number of tenants with cognitive disorder: 0
Total Population: 40
Number of tenant files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kirk Erickson | Manager | Named as Manager providing information about rate increases and staffing |
| Stephanie Cummins | SW MA | Monitor conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Date: May 31, 2007
Visit Reason
A complaint investigation on-site visit was conducted at Rosebush Gardens Assisted Living to investigate allegations regarding tenant care and facility conditions.
Complaint Details
The complaint alleged that Tenant #1 required total care and could not get out of bed or assist with toileting, that the service plan was not reflective of current needs, and that the building’s lounge ceiling was falling down and leaking without repair. The investigation found some allegations unsubstantiated and noted regulatory insufficiencies related to tenant evaluation and service planning.
Findings
The investigation found regulatory insufficiencies in the program's consistent evaluation of tenant cognitive and functional abilities, updating of service plans, and assessment and documentation of tenant health status. No deficiencies were noted regarding the building's ceiling damage or tenant exclusion criteria.
Deficiencies (4)
The program does not consistently evaluate a tenant’s cognitive and functional abilities and health status annually.
The program does not consistently develop a service plan that identifies the tenant’s current needs and any service providers other than the program.
The program did not consistently update the tenant’s service plan by a multidisciplinary team that consists of a health care professional, two staff and the tenant or at the tenant’s request, the tenant’s legal representative.
The program did not consistently assess and document the health status of each tenant receiving personal or health related care.
Report Facts
Current number of tenants without cognitive disorder: 40
Current number of tenants with cognitive disorder: 0
Total Population: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | SW MA | Monitor conducting the complaint investigation |
| Kirk Erickson | Manager | Named in relation to statements about ceiling damage and facility maintenance |
Inspection Report
Monitoring
Census: 39
Deficiencies: 6
Date: Feb 8, 2006
Visit Reason
An on-site monitoring evaluation was conducted at Rosebush Gardens Assisted Living to assess compliance with assisted living program regulations and to evaluate tenant care and services.
Complaint Details
There were substantiated complaints in the area of medications during this certification period.
Findings
The evaluation identified multiple regulatory insufficiencies including inconsistent completion of tenant evaluations prior to occupancy, inadequate individualized service plans that do not address current tenant needs or behaviors, failure to follow acceptable medication protocols, incomplete 90-day medication reviews, and insufficient staff training for delegated nursing tasks.
Deficiencies (6)
The program does not consistently complete functional, cognitive and health evaluations prior to taking occupancy.
The program does not develop service plans to meet the current needs of the tenants.
The program does not develop service plans that address planned and spontaneous activities for those tenants unable to plan their own activities.
The program does not follow acceptable medication protocol.
The program does not complete a 90-day review of medications for those tenants that receive program administered medications.
The program does not have appropriately trained staff.
Report Facts
Current number of tenants without cognitive disorder: 35
Current number of tenants with cognitive disorder: 4
Total Population: 39
Tenant meeting attendance: 23
Tenant interviews: 3
Family interviews: 2
Number of tenant files reviewed: 5
Date of monitoring visit: Feb 8, 2006
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 3
Date: Oct 28, 2004
Visit Reason
A complaint investigation on-site visit was conducted at Rosebush Gardens to investigate allegations related to the inability to account for tenants' narcotic medications.
Complaint Details
The complaint was related to allegations that staff at the program could not account for tenants’ narcotic medications. The complaint was investigated and substantiated with findings of medication errors and missing narcotics.
Findings
The investigation found that the program did not count narcotic medications according to accepted medication protocol, did not appropriately delegate medication administration to a specific staff member, and could not account for missing narcotics. Significant medication discrepancies and potential narcotic theft were identified involving Staff Member #1.
Deficiencies (3)
The program did not count narcotic medications according to accepted medication protocol.
The program did not delegate medication administration to Staff Member #1 appropriately.
The program cannot account for missing narcotics.
Report Facts
Current number of tenants without cognitive disorder: 33
Current number of tenants with cognitive disorder: 6
Total Population: 39
PRN medications given on second shift: 562
PRN medications given on first shift: 12
PRN medications given on third shift: 2
Percentage of PRN medications given by Staff Member #1: 83.8
Unaccounted Percocet tablets: 21
Unaccounted Percocet tablets on Staff Member #1’s shift: 20
Hydrocodone tablets ordered for Tenant #2: 200
Hydrocodone tablets unaccounted for Tenant #2: 146
Vicodin tablets unaccounted for Tenant #3: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Social Worker (SW) | Monitor of the complaint investigation |
| Staff Member #1 | Involved in medication errors and narcotic discrepancies; terminated due to medication error |
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