Complaint Investigation Report

Staff are not following resident's care plan.

On 08/02/2025 LPA interviewed W1 who stated that staff were not following R1’s care plan.

LPA reviewed R1’s Physician’s Report, which indicated diagnoses of Major Depressive Disorder with psychotic symptoms and Post-Traumatic Stress Disorder (PTSD). The Appraisal/Needs and Services Plan (dated 08/30/2025) noted additional diagnoses of ADHD, Reactive Attachment Disorder, and dyslexia, and documented that R1’s conditions would be managed through weekly therapy sessions and regular Interdisciplinary Team (IDT) meetings.

R1’s Physical/Health and Activities of Daily Living (ADL) sections indicated that R1 was independent in these areas. The Care Plan for medication management documented that R1 self administers prescribed medications daily with staff prompts. Review of R1’s Medication Administration Record (MAR) confirmed that R1 was compliant with prescribed medication administration.

On 08/02/2025, LPA interviewed W1 who stated that R1 has PTSD and experiences anxiety when there are frequent staffing changes. W1 further stated that R1 became scared when police were called and they were placed in handcuffs after becoming loud.