Category 2 physical abuse unsubstantiated where the Subject and numerous staff all reported that the Subject did not grab Service Recipient by the neck.

Category 2 neglect unsubstantiated. No evidence Subject 1’s delay in reaching nurse on Service Recipient’s seizure caused impairment. Category 3 neglect unsubstantiated for Subject 2: no duty found.

2 Category 1 sexual abuse allegations found: Subject kissed and touched intimate parts of Service Recipient. 2 Category 2 neglect allegations found: Subject did not maintain boundaries.

Category 2 physical abuse and deliberate inappropriate use of restraints found when the Subject struck the Service Recipient on the right side of his head.

Category 2 physical abuse found when the Subject punched a Service Recipient. Category 3 neglect found when the Subject used not approved de-escalation techniques.

Category 2 neglect found. Subject breached her duty of supervision by leaving the Service Recipient unattended whereupon the Service Recipient obtained a knife. Harm likely.

Multiple allegations of Category 2 and 3 abuse and neglect found. Subject used excessive force and improper technique during restraint of Service Recipient.

Category 1 sexual abuse and Category 2 neglect found. Credible evidence that Subject forcibly touched the Service Recipient’s breast. Subject breached duty to maintain boundaries.

Category 2 abuse and neglect found. Subject breached a duty and conducted an unwarranted restraint with improper technique and excessive force. Harm was likely.

Category 2 neglect not found. Breach of duty to provide supervision not found due to a systemic lack of staffing at the facility.