complaint·August 25, 2025

R1 remained in the hospital for treatment until February 10, 2025 when they were discharged to a Skilled Nursing Facility (SNF). On March 22,2025, R1 returned to the facility, but due to pain, they were taken back to the hospital the next day. Upon arrival, R1 was diagnosed with subacute fractures to their 10th and 11th rib. On June 19, 2025 the Department interviewed R1 who confirmed that they lived at the facility. R1 said they were in independent living and clarified, “it wasn’t for me.” R1 stated “One kid got rough with me.”  R1 explained the kid was a male staff member.  R1 could not recall the date this occurred and stated it occurred before R1 came to the hospital. R1 stated the incident occurred in the evening time when R1 was receiving their “pills.”  R1 stated the male staff member threw R1 against a chair. On May 1, 2025 the Department interviewed Outside Source #1 (OS 1 ), a close family member of R1 who was very familiar with their care . OS1 explained that R1 had the tendency to exaggerate.” OS1 further clarified that on January 31, 2025 R1 fell in their room and fractured their pelvis, not their ribs. OS1 clarified they believed that the new fractures happened sometime after the fall, when R1 was out of the facility and under the care of the SNF. R1 specifically told OS1 that one of the staff members there had “roughed them up.” The Department interviewed several facility staff (S1, S2, S3) that were assigned to care for R1 when they were present on March 22, 2025, and March 23, 2025. No interviews corroborated that staff forcefully repositioned R1 at the facility, and all staff interviewed denied physically abusing R1 at the facility. The Department reviewed hospital records dated 1/31/2025 which indicated that R1’s diagnosis and scans were unrelated to any rib fractures. Records from March 23, 2025 indicate that the main complaint was “pain control,” and that R1 reported they were repositioned roughly at the facility. On 7/23/2025, the Department interviewed the hospital Doctor (OS2) who provided care to R1. OS2 corroborated that R1’s fractures were not present during their January Hospital Stay. They also corroborated that R1 reported that, one day prior to their March Emergency Department (ED) visit, someone at their facility moved them “forcefully.” However, OS2 further explained to the Department that R1’s X-rays showed the rib fractures to be “subacute,” and “chronic,” which meant that they were not new fractures. OS2 further clarified that R1’s report that they were injured one day prior is medically inconsistent with their X-rays, which indicated that R1 had the fractures for some time. It should be noted that Local Law Enforcement (LEO) also investigated the facility abuse allegation. LEO report documented that medical staff believed the injuries most likely occurred when R1 was a patient at the SNF, not at the facility. Due to the inability of the doctor and hospital staff to determine if the injuries were caused due to foul play or negligence, the incident was recorded as a “Miscellaneous Incident.” During the course of the investigation, no corroborating evidence was obtained to support the allegation that neglect/lack of care and supervision resulted in R1 sustaining multiple rib fractures at the facility. Therefore the above allegation is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Executive Director Diana Weinstein A copy of this report along with licensee rights (LIC 9058, 3/22) was provided Executive Director Diana Weinstein whose signature below verifies receipt of these rights.