Complaint Investigation Report

Also, telephone interviews were conducted with five (5) facility staff on 12/21/2025 and 2/06/2026. In addition, facility records relevant to the allegations was reviewed.

Regarding allegation “Staff would limit hot water to resident” – R1 was admitted to the facility on 9/11/2025 with OCD, Panic Disorder, GAD, MDD, ADHD, and Cannabis use disorder. It was also noted that R1 engages in compulsive showering up to 3-12 hours daily, which severely impairs hygiene, sleep nutrition, employment and daily functioning. According to staff R1 also has experienced daily panic attacks, anxiety including vomiting. Staff reported that R1 was admitted to the facility for treatment of the above-mentioned conditions. Staff stated that R1 continued to shower for long hours, during the day, night and early mornings (3am). According to staff this would disturb other residents’ sleep and daily activities. Other residents could not shower since R1 would shower for hours. Staff stated that they always tried to get R1 to shorten shower time by communicating and oversight. Staff interviews revealed that despite all the communication and oversight R1 continued to ignore staff. Interview with the other residents confirmed that R1 would be in the shower for long hours (day and night). Resident reported that the facility staff would try to get R1 to shorten shower time however R1 would continue to shower and would stay for several hours; residents confirmed that R1 would shower late at night for several hours and in the early morning hours (1a.m – 5a.m.). Residents interviewed expressed that this would interrupt their sleep. Interviews revealed that despite staff and residents constantly asking R1 to shorten shower time R1 would continue to shower for hours. Multiple attempts made to reach R1 was unsuccessful. Residents and staff denied ever shutting the facility water.

Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff would limit hot water to resident” is deemed Unsubstantiated at this time.

Regarding allegation “Staff would not allow resident to deny medical transfer to emergency room”.

Records reviewed and staff interviewed revealed that on 09/22/2025 R1 was taken to the ER at the request of the clinical team due to concerns of possible cannabinol hyperemesis syndrome (nausea and vomiting). Staff reported that R1 was not forced to go to the ER; R1 was not feeling well; clinical team was informed of R1’s condition and it was recommended that staff take R1 to the ER. (Continue to LIC9099C)