Complaint Investigation Report

R1 was admitted to the facility on June 1, 2025. LPA reviewed R1's records and found that he has a history of wandering away from staff, yelling obscenities, and other maladaptive behaviors. R1 currently has a 1:1 staff person assigned to him 24 hours a day, seven days a week, due to these behaviors and funded by the placement agency. As a safety precaution, R1 is also equipped with an Air Tag to enable staff to locate him quickly.

LPA reviewed R1’s behavior plan dated 7/1/25 which outlines the techniques staff, including the 1:1 staff, should use when dealing with R1’s maladaptive behaviors.

LPAs reviewed training records from the facility, which indicated that all staff were trained on R1’s behavior plan most recently on September 10, 2025. Staff also stated that a monthly staff meeting is held where each resident’s behavior plan is discussed, with particular focus on R1 because of his high-profile status and 1:1 supervision. The most recent staff meeting took place on October 23, 2025.

LPAs reviewed the facility’s staff schedules for November 2025, which confirmed that R1 has a 1:1 staff scheduled to supervise him 24/7. It was observed that approximately four to five staff members rotate shifts to ensure consistent supervision and implementation of R1’s behavior plan.

LPAs interviewed S1 and S2, who stated that staff are instructed not to be on their cell phones while supervising residents. However, they acknowledged that staff sometimes use their phones and are reprimanded when caught. Both S1 and S2 were unaware of the incident that occurred on November 7, 2025.

LPAs also interviewed S3 and S4, both of whom stated they are aware of R1’s behaviors and emphasized the importance of close supervision. They denied ever witnessing staff using cell phones while providing 1:1 supervision of R1.

This agency has investigated the above complaint. We have found that the complaint is unsubstantiated. Although the allegation may have occurred or be valid, there is not a preponderance of evidence to prove whether the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report was provided.