Inspection Report Summary
The most recent inspection on June 6, 2024, identified deficiencies related to staffing, dementia-specific training, nurse delegation assessments, and a nonworking alarm on an exit door in the memory care wing. Earlier inspections showed a pattern of issues with tenant evaluations, service plan updates, and emergency safety measures, particularly in the dementia-specific program. Complaint investigations were generally unsubstantiated, except for one in 2018 where tenant rights were cited due to medication removal without permission. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s deficiencies have remained fairly consistent over time, with ongoing challenges in staff training and documentation, and no clear trend of significant improvement or worsening.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
65 residents
Based on a June 2024 inspection.
Census over time
Inspection Report
Renewal
Census: 65
Deficiencies: 4
Date: Jun 6, 2024
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #115541-C and Complaint #116990-C.
Findings
Several regulatory insufficiencies were cited related to staffing, dementia-specific education for personnel, and life safety emergency policies. The program failed to ensure nurse delegation assessments within 60 days, dementia training within required timeframes, and a working alarm on one exit door in the memory care wing.
Deficiencies (4)
The Program's Registered Nurse failed to document an assessment ensuring 3 of 3 staff reviewed were competent in assigned tasks and job duties within the first 60 days of employment.
The Program failed to ensure 8 hours of dementia-specific training was completed within 30 days of employment for 1 of 1 staff reviewed hired within the past year.
The Program failed to ensure 2 of 2 staff employed longer than a year had at least 8 hours of dementia-specific continuing education annually.
The Program failed to have a working alarm on 1 of 3 exit doors in the memory care wing which could affect 16 tenants residing in that wing.
Report Facts
Number of tenants without cognitive impairment: 50
Number of tenants with cognitive impairment: 15
Total census: 65
Tenants affected by alarm deficiency: 16
Staff reviewed for nurse delegation assessment: 3
Staff reviewed for dementia training within 30 days: 1
Staff reviewed for annual dementia continuing education: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Betsy Walrath | Wellness Administrator | Named in relation to nurse delegation and training deficiencies; confirmed findings and provided corrective action plans. |
| Staff F | Staff member whose personnel file lacked RN documentation ensuring competency in assigned tasks. | |
| Staff H | Staff member whose personnel file lacked RN documentation ensuring competency and dementia training. | |
| Staff I | Staff member reviewed for dementia-specific continuing education compliance. | |
| Staff C | Staff member who did not complete required dementia-specific training within 30 days. |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Date: Apr 18, 2023
Visit Reason
Investigation of Complaint #107931-C regarding the Assisted Living Program for People with Dementia.
Complaint Details
Complaint #107931-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive impairment: 60
Number of tenants with cognitive impairment: 9
Total census: 69
Inspection Report
Renewal
Census: 41
Deficiencies: 3
Date: Nov 10, 2021
Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for a Dementia-Specific Assisted Living Program, including an investigation of a complaint and an onsite infection control survey.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #100484-C.
Findings
The facility was found to have regulatory insufficiencies related to failure to evaluate tenants within 30 days of occupancy, failure to update service plans within 30 days of occupancy, and failure to ensure all exit doors had operating alarm systems in the dementia-specific program. No deficiencies were cited during the complaint investigation or infection control survey.
Deficiencies (3)
Failed to evaluate 2 out of 4 tenants within 30 days of occupancy.
Failed to update 3 of 4 tenants' service plans within 30 days of occupancy.
Failed to ensure all exit doors in the dementia-specific program contained an operating alarm system.
Report Facts
Number of tenants without cognitive disorder: 34
Number of tenants with cognitive disorder: 7
Total census: 41
Date of violations: Nov 10, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director | Confirmed findings related to evaluation, service plans, and alarm system deficiencies. | |
| Maintenance Director | Confirmed that no exit doors had fully installed operating alarm systems and described partial installation. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Date: May 21, 2019
Visit Reason
Investigation of Incident #82929-I at Waterford at Ames Assisted Living.
Complaint Details
Investigation of Incident #82929-I; no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #82929-I.
Report Facts
Number of tenants without cognitive disorder: 31
Number of tenants with cognitive disorder: 13
Total census: 44
Inspection Report
Renewal
Census: 43
Deficiencies: 0
Date: Feb 12, 2019
Visit Reason
The visit was conducted as a recertification to determine compliance with certification of an Assisted Living Program and included an investigation of Complaint #80754-C.
Complaint Details
Complaint #80754-C was investigated and no regulatory insufficiencies were found.
Findings
No regulatory insufficiencies were cited during the recertification visit or the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 15
Total Population: 43
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Date: Sep 17, 2018
Visit Reason
Investigation of Complaint #77744 at Waterford at Ames Assisted Living.
Complaint Details
Complaint #77744 was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of Complaint #77744.
Report Facts
Number of tenants without cognitive disorder: 17
Number of tenants with cognitive disorder: 13
Total population: 40
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Feb 21, 2018
Visit Reason
The inspection was conducted as part of the investigation of Complaint #73640-C regarding tenant rights violations at Waterford at Ames Assisted Living.
Complaint Details
The deficiency was cited during the investigation of Complaint #73640-C. The complaint involved Tenant #1's rights being violated when medications were removed from the apartment without tenant permission or prior discussion.
Findings
The program failed to ensure that 1 of 3 tenants reviewed was treated with consideration, respect, and full recognition of personal dignity and autonomy. Specifically, Tenant #1's medications were removed from the apartment without permission, causing distress and a violation of tenant rights.
Deficiencies (1)
Failure to ensure tenant was treated with consideration, respect, and full recognition of personal dignity and autonomy as evidenced by removal of medications without permission.
Report Facts
Number of tenants without cognitive disorder: 34
Number of tenants with cognitive disorder: 4
Total census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amber Roberts | Executive Director | Signed Plan of Correction letter dated March 7, 2018 |
Inspection Report
Renewal
Census: 53
Deficiencies: 5
Date: Apr 12, 2017
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program.
Findings
The program failed to evaluate functional, cognitive, and health status prior to occupancy for some tenants, failed to evaluate tenants within 30 days of occupancy for most tenants reviewed, failed to create preliminary service plans prior to admission for some tenants, failed to update service plans within 30 days of admission for some tenants, and failed to ensure nurse reviews were completed every 90 days for tenants receiving medication administration.
Deficiencies (5)
Program failed to evaluate functional, cognitive and health status prior to signing the occupancy agreement for 2 of 5 tenants reviewed.
Program failed to evaluate functional, cognitive and health status within 30 days of occupancy for 4 of 5 tenants reviewed.
Program failed to create a preliminary service plan as required for 2 of 5 tenants reviewed.
Program failed to ensure service plans were updated within 30 days of admission for 2 of 3 tenants reviewed.
Program failed to ensure tenants who received program administered medications were monitored every 90 days as required for 3 of 5 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder: 50
Number of tenants with cognitive disorder: 3
Total population of program at time of on-site: 53
Tenants reviewed for evaluation prior to occupancy: 5
Tenants reviewed for evaluation within 30 days: 5
Tenants reviewed for preliminary service plan: 5
Tenants reviewed for service plan update: 3
Tenants reviewed for nurse review: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vonnie Potter | Executive Director | Interviewed confirming missing documentation and nurse review findings; signed Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Date: Sep 24, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation following a complaint that a staff member yelled at tenants and tenants felt threatened.
Complaint Details
Allegation regarding tenant rights was not substantiated. The program conducted an internal investigation and took corrective action once the situation was recognized.
Findings
No regulatory insufficiencies were identified. The allegation regarding tenant rights was found to be not substantiated after staff interviews, tenant file reviews, and an internal investigation.
Report Facts
Number of tenants without cognitive disorder: 63
Number of tenants with cognitive disorder: 4
Total Population of Program at time of on-site: 67
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 3
Date: Apr 15, 2015
Visit Reason
The inspection was conducted following a complaint/incident involving a staff member failing to give medication to a tenant as requested. The visit included a final incident investigation and recertification monitoring evaluation.
Complaint Details
The complaint involved a staff member failing to administer medication to a tenant who did not want the medication for sleep. The staff member did not administer the medication and subsequently resigned. The incident was isolated and no regulatory insufficiencies were cited related to it.
Findings
No regulatory insufficiencies were cited related to the incident. However, regulatory insufficiencies were found during the recertification survey in areas including dependent adult abuse training, service plans, and nurse review. A Plan of Correction was required.
Deficiencies (3)
Dependent adult abuse training curriculum was not approved by the director of public health.
Service plans did not meet the specific service needs of individual tenants, including lack of interventions for pressure ulcers, weight loss, and impaired skin integrity.
Nurse reviews were not completed with changes of condition to assess and document health status and monitor progress related to previous recommendations.
Report Facts
Number of tenants without cognitive disorder: 59
Number of tenants with cognitive disorder: 5
Total Population of Program at time of on-site: 64
Total census of Assisted Living Program: 64
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 3
Date: Apr 21, 2014
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation following a complaint alleging an unreported elopement and a tenant exceeding criteria for retention at the program.
Complaint Details
The complaint alleged an unreported elopement and a tenant exceeding criteria for retention. The elopement was found not to be reportable as the tenant was cognitively intact and chose to visit a neighboring assisted living program. The tenant did not meet the definition of cognitively impaired requiring reporting. The tenant exceeding retention criteria allegation was not substantiated as no tenants were identified as exceeding criteria.
Findings
The investigation found no regulatory insufficiency related to the unreported elopement allegation. However, regulatory insufficiencies were noted in evaluation, service plans, and nurse review areas, including incomplete evaluations, service plans not meeting tenant needs, and incomplete nurse reviews.
Deficiencies (3)
Evaluation regulatory insufficiency related to incomplete evaluations and failure to determine continued eligibility or changes in services.
Service plan regulatory insufficiency due to service plans not meeting identified tenant needs and not being updated appropriately.
Nurse review regulatory insufficiency due to incomplete nurse reviews, lack of medication review documentation, and failure to monitor tenants after significant condition changes.
Report Facts
Total census: 58
Number of tenants without cognitive disorder: 57
Number of tenants with cognitive disorder: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Date: Feb 12, 2013
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation and Recertification Monitoring Evaluation following allegations related to medication administration errors and medication borrowing among tenants at Waterford at Ames Assisted Living.
Complaint Details
The complaint involved an allegation that a tenant received an incorrect dose of insulin and that a tenant ran out of medications with staff borrowing medications from another tenant. The insulin medication error was confirmed but no regulatory insufficiency was cited. The medication borrowing allegation was not substantiated and no regulatory insufficiency was noted.
Findings
The investigation found that a tenant received an incorrect dose of insulin but no regulatory insufficiencies were noted related to this incident. Another allegation regarding borrowing medications from one tenant to another was also investigated with no regulatory insufficiencies found. However, deficiencies were noted related to incomplete functional and health evaluations and service plans for tenants.
Deficiencies (2)
A program shall evaluate each tenant’s functional, cognitive and health status within 30 days of occupancy and as needed, but evaluations were not completed as required.
Service plans were not developed based on functional and health evaluations as required by regulations.
Report Facts
Tenant census: 43
Medication units given in error: 10
Medication units intended: 2
Dates of complaint investigation: February 12 and 13, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor for the complaint/incident investigation |
| Ann Martin | RN | Monitor for the complaint/incident investigation |
| Rose Boccella | Program Coordinator | Signed cover letter for the report |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 2
Date: Dec 21, 2011
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding missing Hydrocodone and Tylenol tablets at Waterford Assisted Living.
Complaint Details
Complaint/Incident Intake #36906-I involved allegations of missing Hydrocodone and Tylenol tablets for tenants #2, #3, and #4. The complaint was investigated on December 21 and 22, 2011 by Hal L. Chase, RN BSN MPH.
Findings
The investigation found multiple instances of missing Hydrocodone and Tylenol tablets for several tenants, issues with narcotic counts and documentation, and staff not completing narcotic counts as required. The program's medication policy and procedures were reviewed, and regulatory insufficiency was identified related to medication administration by unlicensed personnel.
Deficiencies (2)
Missing Hydrocodone and Tylenol tablets for multiple tenants and incomplete narcotic counts.
Medication administration not always performed by a registered nurse or licensed personnel as required.
Report Facts
Total census: 47
Tenants without cognitive disorder: 45
Tenants with cognitive disorder: 2
Missing Hydrocodone tablets: 3
Missing Hydrocodone tablets: 24
Missing Hydrocodone tablets: 7
Hydrocodone tablets on hand: 16
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Date: Sep 13, 2011
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations of a tenant being sexually assaulted by an unknown man entering the tenant's apartment.
Complaint Details
The complaint alleged a tenant was sexually assaulted by an unknown man who entered the tenant's apartment on multiple occasions. The tenant reported the assault and described the events. Staff and police investigated, and no tenants or staff were identified as physically or sexually harming others. Police records and testing found no forensic evidence. The complaint was not substantiated as a regulatory insufficiency.
Findings
The investigation found no regulatory insufficiencies. The tenant reported an incident involving an unknown man entering the apartment and sexually assaulting the tenant. Police were involved, and testing found no presence of blood or seminal fluid. Staff confirmed safety checks and use of wander-guard bracelets.
Report Facts
Total census: 49
Tenants without cognitive disorder: 48
Tenants with cognitive disorder: 1
Incident date: Sep 8, 2011
Incident date: Sep 7, 2011
Incident date: Sep 11, 2011
Police interview date: Sep 13, 2011
Testing date: Jan 11, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the complaint/incident investigation |
Inspection Report
Monitoring
Census: 59
Deficiencies: 0
Date: Apr 26, 2011
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the recertification documents and evaluate the assisted living program at Waterford at Ames.
Findings
No regulatory insufficiencies were found during the evaluation. Tenant satisfaction was generally positive, and the program did not receive any regulatory insufficiencies during the certification period.
Report Facts
Current number of tenants without cognitive disorder: 55
Current number of tenants with cognitive disorder: 4
Total Population: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Date: Dec 27, 2010
Visit Reason
A complaint investigation was conducted due to allegations that program staff were mean to tenants and did not treat tenants with respect and dignity.
Complaint Details
Complaint Allegation: It was alleged program staff are mean to tenants and do not treat tenants with respect and dignity. Monitoring Observation: A community meeting with 10 tenants found tenants reported staff were helpful and kind with no rude or inappropriate treatment. Two staff interviews confirmed no knowledge of inappropriate incidents. Regulatory Insufficiency: None noted.
Findings
The investigation found no regulatory insufficiencies. Tenants reported staff were helpful and kind, with no episodes of rude or inappropriate treatment. Staff interviews confirmed no knowledge of inappropriate incidents.
Report Facts
Current number of tenants in Dementia Specific Program with dementia: 8
Current number of tenants without cognitive disorder: 53
Total Population: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor during complaint investigation |
| Lori Miner | RN BSN | Monitor during complaint investigation |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Date: Jul 12, 2010
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to tenant care, food service, staffing, structural conditions, temperature control, medication management, and treatment by staff at Waterford at Ames Assisted Living.
Complaint Details
The complaint investigation addressed allegations that the program failed to evaluate a skin rash, failed to notify responsible parties of condition updates, provided inedible food, staff threatened and intimidated tenants, rooms had mold and bugs, tenants could not control room temperature, failed to send medications at discharge, and tenants were not treated appropriately by staff. All allegations were found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were identified during the complaint investigation. Multiple allegations were reviewed including tenant evaluation, nurse notification, food quality, staff behavior, structural conditions, temperature control, medication management, and treatment by staff, with no deficiencies noted.
Report Facts
Number of tenants with dementia: 54
Number of tenants without cognitive disorder: 7
Total population: 61
Tenant age: 87
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Date: Nov 2, 2009
Visit Reason
A complaint investigation was conducted at Waterford of Ames Assisted Living in response to allegations regarding meal quality and nutritional adequacy.
Complaint Details
Complaint #25454-C alleged tenants were not fed meals meeting nutritional requirements and were served freezer burnt food that was not palatable. The complaint was not substantiated as no regulatory insufficiencies were identified.
Findings
The investigation found no regulatory insufficiencies. Observations noted that meals met nutritional requirements, food was served at proper temperatures, and tenant concerns about food quantity and quality were not substantiated.
Report Facts
Current number of tenants with dementia or cognitive disorder: 7
Current number of tenants without cognitive disorder: 54
Total Population: 61
Number of tenants present at community meeting: 22
Date of investigation: Nov 2, 2009
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor conducting the complaint investigation |
| Connie Schaffer | Certification Coordinator | Signed cover letter transmitting the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 3
Date: May 9, 2007
Visit Reason
A complaint investigation on-site visit was conducted at The Waterford of Ames Assisted Living to investigate allegations related to tenant evaluations, service plans, medication administration, staffing, record checks, and tenant rights.
Complaint Details
The complaint investigation was triggered by allegations including failure to complete annual cognitive evaluations, inadequate pain management and interventions for tenants, multiple medication errors, lack of dementia-specific staff education, unmet activity needs, improper criminal background checks, and violations of tenant autonomy and rights. Some complaints were substantiated with regulatory insufficiencies noted, while others were not substantiated.
Findings
The investigation found regulatory insufficiencies including failure to consistently complete annual cognitive evaluations, inadequately designed service plans not meeting individual tenant needs, and inconsistent updating and signing of service plans. Medication administration errors were noted but appropriately addressed. No regulatory insufficiencies were found related to medication administration competency, dementia-specific education, activities, record checks, or tenant rights violations.
Deficiencies (3)
The program does not consistently complete a cognitive evaluation annually as required.
The program does not design service plans to meet the specific needs of the individual tenant.
The program does not consistently update service plans within 30-days of admission and annually and does not have a multi-disciplinary team of three staff sign the service plans as required.
Report Facts
Current number of tenants without cognitive disorder: 47
Current number of tenants with cognitive disorder: 6
Total Population: 53
Medication errors in March 2007: 2
Medication errors in April 2007: 3
Hours of dementia-specific education completed by staff: 6
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 5
Date: Feb 21, 2007
Visit Reason
The inspection was a complaint investigation and recertification monitoring visit conducted at The Waterford of Ames Assisted Living to evaluate compliance with regulatory requirements and address substantiated complaints in tenant evaluation, service plans, medications, staffing, and record checks.
Complaint Details
The complaint investigation was triggered by allegations including improper removal of tenant medical records by the Administrator and RN, medication errors, and shredding of medication documentation. The complaints were substantiated in the areas of tenant evaluation, service plans, medications, staffing, and record checks.
Findings
The investigation found multiple regulatory insufficiencies including inconsistent completion of annual functional, cognitive, and health evaluations; incomplete annual service plan updates; failure to complete nurse reviews every 90 days; lack of appropriate programming and activities; and incomplete employee record checks. No medication errors or document shredding were found.
Deficiencies (5)
The program did not consistently complete annual functional, cognitive and health evaluations.
The program did not consistently complete annual service plan updates.
The program did not consistently complete a nurse review every 90 days.
The program did not provide appropriate programming for each tenant.
The program did not complete appropriate employee record checks.
Report Facts
Current number of tenants without cognitive disorder: 47
Current number of tenants with cognitive disorder: 4
Total Population: 51
Tenants attending community meeting: 12
Tenant files reviewed: 5
Staff files reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tim Perry | Administrator | Named in complaint allegation regarding removal of tenant medical records and medication documentation |
| Hal L. Chase | RN BSN MPH Monitor | Conducted monitoring visit |
| Connie Schaffer | Monitor | Conducted monitoring visit |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Date: Dec 8, 2006
Visit Reason
A complaint investigation was conducted at Waterford at Ames Assisted Living on December 8 and 14, 2006, in response to allegations regarding staffing and medication administration, including concerns about the absence of a Registered Nurse and the handling of insulin-dependent tenants.
Complaint Details
The complaint alleged that on December 8, 2006, the program did not have a Registered Nurse employed and no one to pass medications to 14 insulin-dependent diabetics, some on sliding scale insulin. It was also alleged that a tenant who fell on December 7, 2006, was sent to the hospital and returned with an order for Neuro-checks, but no nurse was available to complete them. The complainant did not report any harm to the tenant who fell.
Findings
The investigation found that the program had seven tenants on insulin, with Certified Nurse Aides and Certified Medication Aides trained by a Registered Nurse to assist tenants. All tenants administered their own injections. The program temporarily used a retired RN and had offered employment to a new RN. No regulatory insufficiencies were noted related to staffing or medication administration.
Report Facts
Number of tenants without cognitive disorder: 57
Number of tenants with cognitive disorder: 0
Total tenants on insulin: 7
Tenants on sliding scale insulin: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tim Perry | Administrator | Administrator of Waterford at Ames Assisted Living |
| Mary Oliver | LISW | Monitor during complaint investigation |
| Jan O’Briant | LISW | Monitor during complaint investigation |
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