Complaint·August 21, 2025

Based off Resident’s needs and service plan dated April 4, 2025, “resident is independent with most activities of daily living and needs help with PureWick External Female Catheter at night. Female staff assist resident. Resident is alert and able to communicate needs. Resident requires one person total assist with catheter and bathing twice a week”. It was reported that R1 was being showered by Staff member (S1) when they were told to stand up and face the wall while S1 proceeded to wash R1’s back, buttocks and legs with wash cloth. R1 was shocked that S1 would wash them in their private area. It was alleged that after S1 washed backside of R1 they reached around to wash front private area to which R1 felt S1 was being rough. R1 stated that S1 did not say anything while bathing R1 and R1 did not communicate to S1 to stop. Police Department Report dated April 30, 2025, stated that R1 did not report incident until 3 weeks later due to fear of S1 retaliating against them. R1 stated that S1 began cleansing R1’s body and made the statement “We’re going to get nice and clean, we’re going to clean the vagina”. R1 stated the statement made them uncomfortable. R1 stated that S1’s hands were where they shouldn’t belong and stated that S1 began to clean their private area. Police Report also mentioned that R1 stated multiple times “Everything is a blur” and when asked about prosecution for incident, R1 stated that they “wanted behavior corrected, but without incarceration”. Interviews were conducted with seven residents (R2-R8) who also received shower assistance from S1, all stated that they do not have any issues with staff while being assisted with showers and have never been touched inappropriately by staff. Interview with R1 stated that S1 had assisted them twice with showering and first time there was no problems. R1 stated that S1 had assisted with R1’s back, buttocks and legs due to R1 unable to reach area. R1 could not recall if they were sitting in the shower or standing up. R1 stated that S1 had vigorously washed private area and R1 was upset because they did not want s taff to wash private area. R1 stated that S1 assisted with the catheter without any incident. R1 stated that they did not want S1 terminated and stated what they believed happened. R1 stated they were satisfied with how facility handled situation by removing staff member from assisting R1 with bathing. CONTINUED ON 9099C Interview with Staff 1 (S1) stated that they only showered R1 twice and stated that before alleged incident, R1 has requested different staff members before to help assist with showers. S1 stated that they have R1 sit on shower chair and helps assist with back, legs and feet. S1 stated that while sitting on shower chair R1 will wash their chest and private areas. S1 stated that they rinse R1 with shower head while R1 uses free hand to rinse off private area without assistance from S1. S1 stated they help assist R1 with the PureWick External Female Catheter which they feel is more invasive due to applying catheter to private extremities. S1 stated that no other residents have complained about them when assisting with care. Interviews with two staff members revealed that S1 was placed on a two day leave while facility conducted internal investigation. Staff stated that S1 was allowed to return to work but was moved to different location to help assist with Activities of Daily living away from R1. Staff interviews revealed that R1’s service plan requires female caregivers to assist with showers. Staff interviews stated that there have been no previous issues with S1. Due to lack of supportive information and inconsistencies of R1’s statements, there is not enough information to support the allegation staff member sexually abused resident while in care. There were no witnesses to incident and R1 is able to communicate how they prefer to be showered. R1 is also able to wash private area without assistance. There is no specific instructions provided on Residents service plan in bathing section other than Resident prefers a female staff member. Therefore, based on interviews conducted and documents reviewed, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted Executive Director Raymond Pellicer and a copy of this report was provided to the facility.