Complaint Investigation Report

Per interviews with residents who witnessed this event, it was R2 who rushed towards R1 and initiated the altercation. It was reported by residents that this altercation happened in front staff, who promptly broke it up and redirected R2. An interview with R1 also reported that R2 was the one who attacked them unprompted while they were engaged in conversation with facility staff. Interviews with staff corroborate this version of events. Further, The Department received a description documenting this in a Special Incident Report submitted by the facility on July 7, 2025.

An interview with Outside Source #1 (OS1) who is familiar with the facility and residents reported not having concerns regarding lack of supervision. OS1 also reported being aware of recent behaviors exhibited by R2.

The Department has investigated the allegations that staff restrained resident and staff handles resident in a rough manor. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated.

An exit interview was conducted with Ron Baum, Licensee, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.