Category 3 neglect substantiated in part because Subject sat on the Service Recipient to administer medication. Remaining allegation sealed.

Category 3 deliberate inappropriate use of restraints and physical abuse found. Emergency exception not found. Imminent threat of harm was not present.

Category 3 neglect substantiated. Subject encouraged service recipient to hit another service recipient likely to result injury or protracted impairment. 

2 allegations affirmed for excessive force and improper technique with no emergency exception. 1 physical abuse reversed: no proof that scratches occurred during restraint.

Category 3 neglect found. Subject not credible. Subject breached her duty by not redirecting the Service Recipient after warning signs of targeted behavior.   

Category 3 physical abuse and neglect found. Subject threw shoe at Service Recipient striking him in the face. Subject not credible.

Category 3 abuse, deliberate inappropriate use of restraints and neglect found. Subject approved a 4-point restraint without proper assessment of Service Recipient. 

Category 3 neglect found. Subject breached duty to maintain accurate medical records by allowing erroneous information to be recorded. Harm was likely. 

Subject's defense of no assistance available unaccepted when she allowed Service Recipients to exit van in parking lot and enter building unsupervised.

Male Subject had duty to bathe and change female Service Recipient. His refusal based on gender was not a policy and was a breach.