Complaint·February 4, 2026

page 2 of 3 During the investigation the department interviewed 1 witness, 3 residents and 5 staff. Resident R1 moved into the Memory Care Unit on 08/03/23 due to wandering behavior. R1 behavior log showed aggressive behavior dated 09/09/24, 11/27/24, 07/21/25, 08/25/25, 08/26/25, 09/09/25, 09/23/25 10/24/25, 10/25/25 10/26/25, 10/28/25 and 10/31/25. R1s Appraisal Needs and Services Plan was updated 10/22/25 and states R1s family to be notified and to try to redirect resident. R1s behavior became a danger to him or herself and facility informed R1s family during an incident and R1s family would arrive to assist in calming R1 down. On 10/31/25 the department received a special incident report regarding R1 having behavior and altercation with staff that occurred on 10/26/25, the incident report stated that R1 had behavior and attempted to kick and punch staff and suffered a finger fracture. On 10/31/25 after the incident R1 went to the hospital via ambulance where R1 became aggressive with hospital staff. R1 did not return to facility after incident. Witness (W1) stated that R1s behavior was due to the facility not forcing R1 to take his/her medication. W1 was reminded that facility staff cannot force Resident to take medication, and it is noted in their file when they refuse medication. W1 stated that the facility should use more force in R1 taking his/her medication. R1s responsible party was called every time resident had behavior and would come to the facility to try to calm R1 down. W1 stated that R1 would calm down once he/she saw them. 5 out of 5 staff stated that R1s aggression and behavior had escalated from the time resident moved into the Memory Care unit and had aggressive episodes and would punch caregivers. 5 out of 5 staff stated that on 10/31/25 R1 had behavior and attempted to pull S1s fingers back and while pulling S1s fingers back was flailing his/her arm. R1 was also observed to have kicked and punched 2 other staff that were present. 3 out of 3 staff stated that R1 had accidentally hit him/herself and R1s nose began to bleed. S3 stated he/she called 911 and shortly after paramedics arrived with local law enforcement and took R1 to the hospital. Page 3 of 3 Amended report On 10/31/2025, at approximately 0951 hours, R1 was brought to the Emergency Department (ED) from the facility by ambulance after becoming agitated and physically engaging with S1 while receiving his/her morning medication. R1 was diagnosed with a “minimally displaced nasal bone fracture, medical documentation determined that the fracture could have resulted from an unwitnessed fall, or from an altercation, because R1 noted that he/she was elbowed in the nose by S1. On 10/30/2025, R1 suffered an unwitnessed fall, staff called EMT’s, but since R1 was at baseline, R1s POA preferred R1 not to be transferred to the ED. S2 has had training in handling critical incidents and is called when staff need assistance with resident who are having behavior in de-escalating techniques including redirecting agitated residents. S2 uses techniques like using a preferred activity to diffuse resident behavior. S2 stated that when a resident attempts to physically engage with staff the staff disengage and move residents nearby for safety and attempt to de-escalate the situation. S2 stated that after any incident the family is immediately notified as well as the Residents primary care physician. S2 stated that R1s behavior is triggered when R1 has nothing to do. S2 would give R1 daily tasks like pouring water into cups when handing out medication to residents to engage R1. R2 stated that he/she had seen R1s recent behavior had become more aggressive. R2 stated that R1 on one occasion was seen pulling on S1s fingers and S1 was not able to pull away and R1 was out of control and had uncontrollable rage. R2 stated that he/she felt that staff did not overstep their boundaries with R1. R2 stated that R1 could possibly hurt him/herself due to the flailing arms and trying to hit staff. Based on investigation, interviews conducted, and records reviewed, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. This report was reviewed with Matthew Zahodne, and a copy of the report was provided.