complaint·November 24, 2025

(Continued From LIC9099) Resident #1 (R1) has a documented history of psychotic behavior, including episodes requiring emergency services intervention. A recent physician report lists diagnoses of asymptomatic COVID-19 and anxiety, with no indication of mild cognitive impairment. The report also notes that R1 is non-compliant with medication and requires assistance with administration. Staff interviews revealed that no one witnessed or admitted to recording R1. S1 denied using a recording device but stated they contacted their supervisor via cellphone and placed the call on speakerphone to allow the supervisor to hear R1’s behavior and the interaction in real time. Staff denied speaking to R1 inappropriately and reported that redirection is commonly used to manage R1’s behaviors, with positive results. Resident interviews were attempted but could not be completed due to significant cognitive limitations among potential witnesses. Interviews with outside sources revealed no concerns regarding staff behavior. Two outside source confirmed witnessing psychotic episodes involving R1 and stated that staff interactions during those episodes were appropriate and professional. No inappropriate staff behavior was observed or reported by other outside sources A review of facility records revealed no complaints, grievances, or incident reports involving S1. LPA observations during the visit showed no evidence of inappropriate staff conduct or misuse of personal devices. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrato Unique to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.