Complaint Investigation Report

Staff 1 (S1) denied all allegations and reported that R1 is frequently noncompliant with prescribed medications and often refuses to take them. S1 stated medications are offered as prescribed and documented when refused. S1 reported that staff continue to provide assistance and support despite R1’s behaviors. OS1 and OS2 reported that R1 has a history of exaggerating events and making false statements when upset. Regarding the incident, OS1 reported that R1 and another resident were involved in a verbal altercation, during which R1 was threatened the other resident. Law enforcement responded and instructed staff to have R1 remain in their room while other residents temporarily exited for safety. OS1 stated staff did not physically touch or abuse R1. OS1 and OS2 also reported no concerns regarding medication administration, meals, or laundry services.

R1 alleged being held down and verbally abused but provided inconsistent information and did not provide requested supporting evidence. R1 initially stated they had text messages and video but later stated the messages were deleted. R1 did not provide details explaining the circumstances of the alleged restraint. R1 also alleged being denied food after surgery; however, R1 reported that staff limited food portions temporarily monitored to prevent vomiting following appendectomy discharge. R1 additionally alleged a dog bite but did not provide details or evidence.

The Administrator and House Manager stated R1 voluntarily discharged on February 25, 2026, after residing at the facility for approximately six weeks. The Administrator reported that R1 was frequently aggressive toward staff and residents, including throwing a phone and using derogatory language. The Administrator stated R1 repeatedly refused prescribed medication, and staff transported R1 to urgent care to obtain requested PRN medication. The Administrator denied that R1 was ever locked in their room and stated law enforcement did not take action when called. The Administrator reported meals, alternative food options, transportation within policy, and laundry assistance were consistently provided.

Based on interviews conducted and information obtained, there is insufficient evidence to support the allegations that staff treated R1 without dignity, physically abused, verbally abused, or denied medication to R1. Therefore, the allegations are unsubstantiated. An unsubstantiated finding means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to . Her signature on this form confirms receipt of the documents.