Star Guides

Out of compliance, complaint, investigation inspection : R380-600-7(16)(a)-(e) Critical incidents reporting requirements

The licensee was out of compliance with R380-600-7(16)(a) by not submitting a critical incident report to OL within one business day. During an investigation, the information gathered substantiated that a critical incident occurred on 05/12/2025 and was reported to the Office of Licensing on 05/16/2025.

Out of compliance, complaint, focus inspection : R501-1-11(2)(a)-(f) Licensed Program Complaints and Critical Incidents

The provider was out of compliance for failing to report a client rights critical incident to the Office of Licensing. During an on-site inspection, multiple interviews disclosed that one staff yelled at, swore at, and physically mistreated a client and a second staff physically mistreated a client. The staff involved failed to report this as required by rule.

Out of compliance, complaint, focus inspection : R495-876-5(1)(a)-(m) Code of conduct

The provider was out of compliance with this rule by mistreating a client, by compromising the health and safety of a client, and by failing to deter others from acting. During an on-site investigation inspection, multiple interviews disclosed that a staff yelled, swore at, pulled and shoved a client up a hill that needed a break during a hike. Other staff present failed to intervene and prevent the staff from pulling and shoving the client and an additional staff eventually assisted the first staff in pulling and shoving the client up the hill.

Out of compliance, complaint, focus inspection : R501-1-26(5)(a)-(y) Congregate care behavior management policy

The provider was out of compliance with this rule by staff using physical restraint as a convenience for staff. During an on-site investigation inspection, multiple interviews disclosed that two staff members physically restricted a client’s freedom of movement and normal access to their body. During this incident, a client was sitting and resting during a hike. The client was not a harm or danger to themselves or others. The client had a backpack secured to their body. The staff grabbed the client by their backpack and left shoulder, pulled the client to a standing position, and used the backpack to shove the client up a hill. When the client sat down to rest this happened a second time. This is a repeat citation.