The Estates At Excelsior Llc

jeopardy to resident health or safety

when she entered R1's room, she saw R1 on the bed, and the DON was hitting R1. NA-A separated the two and the DON walked towards the door.

While NA-A was attempting to calm R1 down, the DON came back and pushed R1 down on the bed again and started fighting with her. It took two staff to pull the DON off R1. In 20 years, NA-A had never witnessed a staff member fighting and cussing with a resident.

She felt intimidated by the DON, so did not tell the truth on her first written statement.

Interview on 11/25/25 at 3:41 p.m., R3 stated the DON brought her to room [ROOM NUMBER] to discuss her complaint with R1 regarding the shared space.

She observed the DON move R1's table, and R1 was standing behind her shaking her fist. R1 then ran up and started biting the DON. R3 ran out of the room frightened by R1 and what R1 would do to her.

Interview on 11/25/25 at 4:06 p.m., DON stated R1's tray table was pushed into R3's space. DON told R1 the table could not push against the privacy curtain and moved it away. R1 pushed the table back and when DON went to move the table again, R1 lunged at her biting her elbow.

The more DON told R1 to stop biting, the harder she bit. DON pushed R1 to a sitting position on the bed, but R1 got up again. DON asked R1, You want to fight me? when the other staff arrived. DON was angry and in a lot of pain. DON left the room to clean her wound.

After the police spoke with R1, R1 apologized to her.

DON added, when R1 stood up again she was frightened and in shock.

She realized she should have left the room but I got upset.

Interview on 11/26/25 at 10:34 a.m., the administrator stated after the incident on 11/14/25, he reached out to his supervisor. He was instructed to have the DON fill out a workers' compensation form. He had R3 transferred to another room for safety and spoke with the police.

The police did not have any concerns and offered to transfer R1 to the hospital but there would be a delay. He spoke with NA-A and LPN-A but what they told him was unclear to the actual events. He did not interpret what they were saying was an indication of rough handling by the DON. He interviewed the DON but did not receive her written statement until 11/17/25.

Once he spoke with NA-A on 11/16/25, he immediately told his supervisors to escalate the investigation.

The DON was suspended pending the investigation. He called the facility to complete a skin assessment, and a small bruise was found on R1's chest. He reported his findings to the state on the evening of 11/16/25 at 6:54 p.m.

Interview on 11/26/25 at 1:39 p.m., registered nurse (RN)-A stated while talking with R1 after the incident she thought she heard the DON and became anxious. RN-A told R1 the DON was not at the facility. If she had been at the incident, she would have reported the DON's actions towards R1 to the administrator right away.

The facility policy Abuse Prohibition and Vulnerable Adult policy dated 4/20/25, indicated all staff are required to report a situation of abuse immediately. A prompt investigation would include determining probable cause.

All staff who witness abuse are responsible to report the incident by notifying their supervisor immediately. If the alleged perpetrator was a staff member, they would be suspended immediately pending the investigation findings. If the alleged perpetrator was a department head, their supervisor would be notified or [NAME] President of Social Services and Behavioral Health.

Definition of abuse was a willful infliction of injury.

Suspected abuse would be reported to the state no later than 2 hours after the incident.

Employees are encouraged to report any reasonable suspicion of a crime and they would be protected from retaliation.

The PNC IJ began on 11/14/25, was removed on 11/17/25, when it was verified the facility implemented the following:- All staff were re-educated on what constitutes abuse, when to report and what allegations to report.- DON was suspended, then terminated.

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