Complaint Investigation Report

Resident 2 (R2) stated that R1 has swung at them in the past and is typically the aggressor in conflicts. R2 reported they have not seen or heard staff make fun of residents or physically pick up or throw any resident to the ground. R2 stated they heard R1 swung at a staff member outside the facility and fell while staff was redirecting R1 back to the home. R2 indicated that residents have complained about R1 not showering but denied staff ridicule.

Staff 1 (S1) stated that R1 is usually the aggressor when conflicts arise and tends to escalate when not getting their way. S1 denied any staff physically shoving or pushing R1 to the ground and denied staff making fun of R1. Staff 2 (S2) reported hearing of an incident outside the facility in which R1 swung at a staff member and subsequently fell. The Administrator reported that R1 is frequently aggressive toward residents and staff, particularly when R1 does not get their way. The Administrator clarified that a reported remote control incident involved another resident accusing R1 of taking the remote, which resulted in R1 becoming aggressive; staff were not involved in that altercation. The Administrator also reported that R1 will no longer reside at the facility after March 3, 2026, as R1 requires a higher level of care. The facility is licensed as a Level 3 Adult Residential Facility, and R1 will be transitioning to a Level 6 facility. The Administrator stated the facility is not equipped to provide one-on-one supervision and cannot adequately monitor R1’s behaviors in the community.

Record review reflects R1 was admitted on January 25, 2025, is not conserved, and has diagnoses of Intellectual Disability, Cerebral Palsy, Autism, and Epilepsy/Seizure Disorder. Documentation describes R1’s behavior as oppositional, mild in severity, and occurring monthly. Records note R1 has an unsteady gait resulting in trips and falls in the community. R1 is independent in activities of daily living but requires reminders for hygiene and clean clothing. R1 has a speech impediment but is able to communicate verbally and in writing. Documentation also reflects difficulty budgeting money, a history of panhandling, heavy smoking, and independent use of public transportation.

Based on interviews conducted and records reviewed, there was insufficient evidence to support the allegation that staff failed to treat R1 with dignity or physically handled R1 in an inappropriate manner. The allegation is therefore unsubstantiated. An unsubstantiated finding means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to . Her signature on this form confirms receipt of the documents.