complaint·January 28, 2026

Per the facility incident report dated January 19, 2026, R2 initially reported the incident to their family member who notified the facility, R1 denies the incident occurred as reported, and, although the incident itself was not witnessed or recorded, R1 will be evicted as they make other residents uncomfortable and facility staff will conduct additional checks on R2 in the meantime. LPA interviewed COO who confirmed the information provided on the incident report. LPA interviewed R2 who confirmed that R1 touched and spoke to them inappropriately as reported, stated they did not consent to R1’s behavior, and reported that R1’s behavior had made them uncomfortable. Per COO and R2’s Physician’s Report dated April 1, 2024, R2 does not have confusion. LPA interviewed R1 who admitted to touching R2 inappropriately, but claimed they did it in an innocent manner. Per COO and R1’s Physician’s Report dated August 15, 2025, R1 has mild cognitive impairment. When interviewed, COO stated that no one else saw the incident and it was not captured on camera, but the facility believed R2’s allegation and is evicting R1 in response. LPA reviewed R1’s Eviction Notice dated January 20, 2026, which confirms R1 is being evicted. Per COO, although R1 does have a history of making inappropriate comments to other residents, the other residents never requested action be taken against R1, and previous reports of inappropriate touching were not substantiated. LPA interviewed witnesses, staff, and other residents and was unable to obtain information confirming that R1 has previously engaged in behavior as inappropriate as their behavior on January 17, 2026. COO stated that on January 18, 2026, when the facility was notified of the incident by R1’s responsible party, the facility investigated the situation and notified local law enforcement, local law enforcement investigated the situation, stated they would review the matter to determine if additional action is warranted, and have not returned to the facility to provide an outcome. R2’s consistent statement of events, video footage seen by R2’s responsible party and facility staff confirming R2’s timeline of events, and R1’s admission of inappropriate behavior corroborate R2’s allegations against R1. However, the facility took proper action after the incident was discovered and information was not obtained showing that the facility should have taken action against R1 prior to this incident, as R1 had no confirmed history of inappropriate touching prior to this incident. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. Per the facility incident report dated January 19, 2026, R2 initially reported the incident to their family member who notified the facility, R1 denies the incident occurred as reported, and, although the incident itself was not witnessed or recorded, R1 will be evicted as they make other residents uncomfortable and facility staff will conduct additional checks on R2 in the meantime. LPA interviewed COO who confirmed the information provided in the incident report. LPA interviewed R2 who confirmed the details of R1 entering their room and engaging in appropriate behavior as reported, stated they did not consent to R1’s behavior, and reported that R1’s behavior had made them uncomfortable. Per COO and R2’s Physician’s Report dated April 1, 2024, R2 does not have confusion. LPA interviewed R1 who admitted entering R2’s room and asking R2 for a kiss, but appeared confused and gave conflicting information about what else took place during this incident. Per COO and R1’s Physician’s Report dated August 15, 2025, R1 has mild cognitive impairment. When interviewed, COO stated that no one else saw the incident and it was not captured on camera, but the facility believed R2’s allegation and is evicting R1 in response. LPA reviewed R1’s Eviction Notice dated January 20, 2026, which confirms R1 is being evicted. Per COO, although R1 does have a history of making inappropriate comments to other residents, the other residents never requested action be taken against R1, and previous reports of inappropriate touching were not substantiated. LPA interviewed witnesses, staff, and other residents and was unable to obtain information confirming that R1 has previously engaged in behavior as inappropriate as their behavior on January 17, 2026. COO stated that on January 18, 2026, when the facility was notified of the incident by R1’s responsible party, the facility investigated the situation and notified local law enforcement, local law enforcement investigated the situation, stated they would review the matter to determine if additional action is warranted, and have not returned to the facility to provide an outcome. When interviewed, R1 and R2 both confirmed that R2’s door was not locked when R1 entered. COO stated that the facility has previously offered to help R2 lock their door, but that both R2 and their responsible party refused, stating R2 does not want their door locked. R2’s responsible party corroborated that R2 does not like locking their door. The information obtained did not corroborate that the facility could have prevented R1 from entering R2’s unlocked room and showed that the facility responded properly after the incident was discovered. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.