Complaint Investigation Report

LPA’s records review of incident reports revealed the following incident reports were received and reviewed by the Regional Office. 08/05/2025 at approx 8pm, Resident #1 (R1) entered Resident #2 (R2)s bedroom, attempted to push R2 out of R2's bed. Four (4) staff intervened and relocated R2 out R2's bedroom. After R2 was relocated R1, exited the room and returned to R1's room on their own accord. Staff conducted a wellness check and observed R1 laying in bed. Staff reminded R1 not to enter any roommates room without permission. There were no reported incident for the rest of the evening.

On 08/04 - R1 had a behavior which resulted, property destruction in R2's room, On 07/31, R1 had a behavior which resulted, property destruction in R2's room, on 07/28, R1 had a crisis event, which resulted in property destruction of patio furniture and a garbage can, On 07/27, R1 had a behavior which resulted in R1 striking another resident, On 07/25, R1 had a behavior which resulted in property destruction in bathroom, On 07/22, R1 threw a staff member’s phone outside of car window, which resulted in the phone being destroyed in oncoming traffic, on 07/14, R1 had a behavior which resulted in property destruction in the kitchen, On 07/13, R1 had a behavior which resulted in property destruction, On 07/09, R1 had a behavior which resulted in R1 striking another resident and property destruction in R2’s room.

Interviews conducted and records review revealed since December 2024, staff have observed in increased of incidents documented from February 2025 through July 2025. R1’s behaviors have been attributed to multiple factors, including R1’s hypersensitivity to environmental stimuli, limited communication abilities, interpersonal tensions with R2 and system-wide operational changes such as staff turnover and administrative change. As a result the facility has responded with weekly staff training's that cover de-escalation, sensory trigger management, positive reinforcement and structured engagement. The facility has also modified R1’s bedroom so that the doorway faces the living room instead of directly facing R2’s room to minimize accessibility into R2’s room. In the past Staff had sat in the hallway to monitor R1 and redirect R1 when they start walking toward R2’s room, however once R1 is in the middle of a behavior they can be difficult to redirect often knocking staff over or striking them in the process. Staff also conduct 15-minute checks, but due to the nature of R1’s behaviors, it’s not always sufficient to prevent incidents. R1 tends to ruminate on issues for days and sometimes reacts to events long after they occur. R1 may express frustration or act out late at night, which makes behavioral tracking more complex. R2 also refuses to close or lock their door. When staff attempt to close it, R2 resists and becomes combative.