complaint·July 20, 2023

Review of physician’s report revealed that Resident 2 (R2) had a diagnosis of dementia, was confused, disoriented, and had wandering and Sundowning behaviors. Interviews with staff revealed that R2 had a history of wandering into other residents’ rooms but was redirectable. Interviews with staff revealed that on 1/17/2023, R1 was observed in a common area touching R2's genitals over R2’s clothing. Staff separated R1 and R2 and instructed R1 not to touch anyone. On 1/18/2023 at around 5:00 am, R1 and R2 were observed to be in R1’s room laying on the bed together while R1 was fully undressed and R2 was not wearing any clothing below the waist. R2 had their hand on R1’s genitals with R1’s hand covering R2’s hand. Staff called for assistance to separate both residents and called local law enforcement who responded to the facility. On 1/18/2023, facility management arranged and paid for R1 to have a private caregiver to provide 1 on 1 supervision in order to protect other residents, including R2. The private caregiver began supervising R1 on 1/19/2023. The private caregiver was tasked with ensuring residents did not enter R1’s room, accompanying R1 in common areas, redirecting R1 when they attempted to expose themselves or engage in inappropriate behaviors, and report all incidents to facility management. The private caregiver was also given a towel to cover R1 when they did expose themselves and escort R1 back to their room. Interviews with staff revealed that R1 had stated to staff on multiple occasions that they would stop touching and exposing themselves to staff and other residents, but R1 continued with their behavior. Interviews with R1 revealed that R1 understood that their behavior was inappropriate but continued to engage in those behaviors. On 1/19/2023, R2 reported to staff that they had genital pain and R2 was transferred to the hospital for evaluation. R2 returned to the facility the next day with no new medications or diagnosis. Interviews with R2 revealed that R2 could not recall any of the interactions with R1. Interviews with staff revealed that R2 could not understand that the interactions between R1 and R2 were inappropriate. On 1/20/2023, R1 was assessed by a medical professional and prescribed R1 a medication which calmed R1 but did not cause the behaviors to stop. Interviews with staff revealed that facility management reached out to R1’s responsible party who was not responsive to the facility’s steps to mitigate the behaviors. Continued on LIC9099-C page... Interviews with staff revealed that R1 refused to be re-evaluated and became aggressive with staff when the topic of medical evaluation was discussed. On 1/26/2023, R1 was given a 30-day eviction notice for failure to follow facility rules and was evicted from the facility on 2/20/2023. Interviews with staff revealed that R1 did not have any incidents with other residents in which R1 was able to touch other residents once the private caregiver started on 1/19/2023. R1 continued to expose themselves to staff and other residents until R1 was evicted from the facility on 2/20/2023. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Executive Director Christopher Burk, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).