Complaint·February 5, 2026

The investigation included a review of facility reports, medical records, and interviews. Facility records showed that R1 received bed baths on 9/23/2025 and 9/26/2025 by hospice staff, which matched the timing of R1’s statements. However, no staff reported witnessing or hearing R1 make similar statements outside of these incidents. Records confirmed that R1 has a diagnosis of Alzheimer’s dementia, with periods of confusion, disorientation, sundowning behaviors, and depression. Family members reported that R1 had made similar allegations in the past at another placement, which reportedly stopped after medication was prescribed and later R1’s allegations resumed when those medications were discontinued for hospice care. During a follow-up interview conducted on 10/23/2025 by the Department, R1 did not disclose any sexual assault. Due to the lack of physical evidence, the absence of witnesses, inconsistent disclosures, and R1’s documented cognitive impairment, there was insufficient evidence to confirm that a sexual assault occurred. The allegation that R1 was sexually assaulted by staff while in care could not be proven or disproven, and therefore the finding is UNSUBSTANTIATED. Note that an unsubstantiated finding means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited during this visit. An exit interview was conducted with AD and a copy of this report and appeal rights were provided.