Incident investigation·October 24, 2022

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management visit to the facility and met with the Executive Director (ED), Ivan Saa. An incident report was received 10/18/2022 which stated that resident #1 (R1) felt that she was violated during showering. To investigate on 10/24/2022 at 10:45am, LPA interviewed the ED and on 10/24/2022 at 11:45am, LPA interviewed R1. The staff member was unavailable for questioning, but ED provided their contact information. Interviews revealed that R1 did not suspect the violation was sexual in nature, but rather the resident was allegedly being to rough during showering and wanted the caregiver to be more gentle. Interviews with the ED revealed that caregivers are on standby, hand the wash cloth to the residents and assist as needed or at the resident's request. The ED filed a police report, but after questioning R1, they decided that no crime was committed and no further investigation was required. The responsible party, R1's son, was also notified and stated that R1 has a history of telling stories and that it was more than likely not true. Since the incident, the caregiver in question no longer assists R1 with showering and the Executive Director has had in-service training for all staff regarding the matter. A file review revealed that R1 is not able to bath on their own and that R1 is a fall risk. ED also stated that they will be holding additional in-service training for staff on how to better care for their residents. No further action at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.