complaint·July 14, 2025

[Continuation of LIC 9099] An additional review of R1’s records revealed they had been sent to the hospital on several occasions for behavioral issues including suicidal thoughts. R1’s facility records dated October 8, 2024, revealed they underwent a reassessment that showed R1 required moderate interventions, redirection, and status checks. On October 8, 2024, the reassessment added status checks to their care plan. An interview conducted with the Residential Service Director (RSD) on July 11, 2023, revealed R1 had severe mental health issues, never had a roommate, and everyone at the facility had private rooms unless they were a couple. The RSD also revealed that R1 was fixated on their roommate (referred to as R2) from their previous placement who R1 believed was trying to kill them by feeding them sweets (R1 is Diabetic) after R1 had put R2 in their (R1's) trust. A review of facility records corroborated the RSD’s statement regarding R1 having a private room. An interview with the Executive Director (ED) and a facility tour corroborated the information provided by the RSD. Based on staff interviews and facility and resident records reviews the allegation was determined to be UNSUBSTANTIATED, an unsubstantiated finding means there was not a preponderance of evidence to prove the violation occurred. An exit interview was conducted with the ED and a copy of the report and Licensee Rights (LIC 9058) were provided. Signature below confirms receipt of the reports. *This is an amended version of the original report delivered on July 15, 2025.