Incident investigation·October 24, 2024

On 10/24/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding a SOC 341 the Department received. LPA met with Resident Care Director and explained the purpose of the visit. The incident occurred on 10/7/2024 when R1 had an unwitnessed fall and was transported by medical services to the emergency room for an assessment. It was then at the emergency room when R1 alleged "sexual assault by adult". Police report was additionally filed by the hospital. Facility was not notified until facility observed the following on R1's discharged paperwork. LPA and Resident Care Director discussed that roughly on the same time, R1 had urinary tract infection (UTI) then an unwitnessed fall which R1 then alleged the following accusation. Resident Care Director stated based on R1's history, R1's confusion increase when R1 has UTI. Resident Care Director stated that based on conversation with R1's responsible party, R1 has the tendency to talk about sexual assault when in the state of confusion. Resident Care Director stated R1 has chronic UTI's prior to admission, which R1 has been on cranberry supplements. Additionally, Resident Care Director stated there are no male caregivers at the facility. Facility is licensed for 32 ambulatory and 1 non ambulatory residents, Resident Care Director stated only one resident in care has dementia. Resident Care Director stated due to current census, staff has been providing residents in care with frequent hourly routine checks to ensure health and safety. At this time, LPA requested a copy of R1's hospital discharge paperwork, medication list, LIC 602 and LIC601/ID/Emergency Contact. The following incident remains under review by the Department until notified otherwise. Exit interview conducted and a copy of the report was provided.