complaint·May 29, 2025

During the investigation, the Department collected pertinent resident records, outside source records and conducted various interviews. According to details of the allegation, R1 reported that on December 11, 2023, Staff 1(S1) lifted and threw R1 during an emergency evacuation at the facility causing fractures to multiple ribs. Medical records confirmed that on December 12, 2023, R1 was diagnosed with fractured ribs. Interview with S1 revealed that S1 did not assist R1 in the evacuation on December 11, 2023, and S1 was focused in extinguishing the fire in a residents’ room. Interview with Staff 2, who was also present on the date of the incident, revealed R1 was not assisted out of the facility as R1 is ambulatory. Records collected revealed that R1 was later found with a fire lighter and cardboard on the date of the fire and was considered a suspect of arson to the facility. During further interviews it was found that on December 9, 2023, R1 had an outburst where R1 urinated on the floor of the facility, destroyed holiday decoration and hit Staff 3 (S3) and Staff 4 (S4). Interview with S3 and S4 revealed R1 slapped S3 and punched S4; attempts of S4 to intervene in further violence on S3 and residents, resulted in S4 and R1 slipping on the urine-soaked floor, causing S4 to fall on top R1. S4 believes the fall may have caused R1’s fractured ribs. After the incident, S3 and S4 assessed R1 for injuries and R1 reported to be fine. Records collected confirmed R1 has assaulted multiple staff and destroyed facility property. Interview with an outside medical source established that facility attempted to protect R1 from self and others and injuries may have not been an act of abuse. Further interviews revealed that R1 has a history of chest pain, and according to Staff 5 (S5), R1 reported having chest pain as of December 6, 2023. Interview with R1 established that R1 believed their ribs were injured as of the first incident on December 9, 2023. Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove p hysical abuse to resident by facility staff resulted in serious bodily injuries. An exit interview was conducted with Executive Director Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22 ) were provided .