Facility Evaluation Report

***This is an amended report*** On 10/30/23 at 2:35 p.m., Licensing Program Analyst (LPA) Greg Clark delivered an amended report to reflect the facility census of 5. On 10/16/23 LPA conducted a case management visit as a follow-up to a substantiated allegation of physical abuse. LPA met with Nathaniel Reed, Administrator and explained the purpose of the visit.

On June 22, 2023, the Department concluded a complaint investigation and substantiated an allegation that staff had physically abused a resident (R2) while in care resulting in bruises and scratches. This complaint was received on February 9, 2023.

On February 2, 2023, staff (S1) was observed by a witness (W1) outside the facility’s front door kicking R2 four times on their back. W1 was in shock and looked away. W1 did not know when the kicking had stopped. W1 did not check R2’s back but observed a bruise on the right eye and dried blood behind R2’s ear. W1 spoke to another resident (R4) who was also being transported from the home to the day program and R4 stated that R2 gets constantly beat with a stick on a daily basis by different staff. When R2 arrived at the day program, staff observed cuts and bruises on R2’s face and ear. Photos of the injuries, incident reports, and trip logs were obtained by the Department which corroborate W1 and day program staff observations regarding R2’s physical appearance.

During the Department’s investigation, interviews conducted with other residents (R4, R5, and R6) revealed that they had witnessed S1 use a yellow stick to hit R2 on multiple occasions. These residents stated that S1 keeps the stick in their room at the facility under S1’s bed. During onsite investigation at the facility, the stick was discovered by the Department under the bed of S1 and confirmed by the administrator that the stick belonged to S1. The Department determined at the conclusion of the complaint investigation that S1 had used the yellow stick to hit R2 on multiple occasions.