complaint·July 3, 2025

The investigation revealed the following: Allegation- Staff did not prevent resident from engaging in inappropriate interactions with another resident in care. The details of the complaint alleged that a resident in the facility exposed themselves to another resident (R1) in care. On 7/3/25, from 9:30am-12:00pm, the department interviewed staff (S1-S5) and residents (R1-R7) regarding the allegation. All staff (S1-S5) denied the allegation that Staff did not prevent resident from engaging in inappropriate interactions with another resident in care. Staff stated that they did not witness any inappropriate interactions between residents that was sexual in nature. They further state that no other resident to their knowledge has been observed exposing themselves to other residents or staff. They state that a resident (R1) in the facility has been known to fabricate and have delusions that people were doing things to them which turned out not to be true, once investigated. Staff stated that (R1) has a mental condition that brings about paranoid delusions, agitated behavior, and psychosis. The department interviewed residents (R1-R7) about the allegation and 6 of 7 residents that were interviewed, denied any knowledge of inappropriate behaviors from residents that were sexual in nature. They stated that they have not witnessed or were aware of anyone exposing themselves in the facility. While resident (R1) declined to participate in the interview. The department reviewed the Physicians Report (Dated: 03/20/2025), Resident Appraisal (Dated: 03/20/2025), Medication List (Dated: 07/01/2025-07/31/2025), and Preplacement Appraisal (Dated: 03/12/2024) for (R1) and observed that the resident has a medical history of schizoaffective behavior, psychosis, and paranoia. The department also observed that the resident is taking aripiprazole and lithium medication, which is used to treat psychosis and bipolar disorder. Symptoms of psychosis include delusions, hallucinations, and agitation. During an episode of psychosis, a person’s thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not, according to the National Institute of Mental Health website www.nimh.nih.gov . Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff did not prevent resident from engaging in inappropriate interactions with another resident in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur because of neglect, therefore the allegation is Unsubstantiated . No citations were issued. An exit interview was conducted with Lorenzona Elvie Medina, Administrator, and a hard copy of this Complaint Investigation Report was provided.