complaint·March 18, 2025

(Continued from LIC9099) Due to the accusation S2 stated that they intentionally avoided being near R1 to reduce R1's delusion that S2 was taunting them. Additional staff interviews revealed that the situation was not plausible to have occurred and that certain details of R1's story were found to be proven false. Staff believed that R1's progression of cognition decline likely caused them to merge both factual and fictitious events together, creating a situation that did not happen. LPA interviewed R1 during an unannounced facility visit and R1 sustained that the incident occurred. However, R1 was not able to be completely qualified as a valid historian, due to R1 not being able to recall basic information, and offering statements during the interview that were implausible. Two outside sources familiar with R1 were contacted regarding the allegation. One outside source confirmed being told by R1 that the event occurred, however no additional information was provided to them to corroborate the claim such as witnesses, date, time etc. The second outside source did not respond to requests for interview. Facility records and medical records were reviewed regarding the allegation. The records revealed that R1 experienced a change in condition due to an acute infection, which resulted in unusual behavior and paranoia. Facility records showed that R1 was being monitored by staff due to the changes, and monitoring was continued throughout their medication regimen to resolve the infection. The evidence indicates that R1 was experiencing a change in condition resulting in a delusion due to an acute infection. Records and interviews revealed that the incident was implausible due to specific details provided by R1 being proven untrue, and record evidence that the staff member in question was neither working the day of the incident in question and was also no longer in the position claimed. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.