complaint·December 4, 2023

Review of R1’s medical assessment and appraisal documents dated September 2023 did not reveal any history of inappropriate, aggressive, Sundowning, or wandering behaviors. Review of R2’s medical assessments dated May 2023 revealed that R2 had a diagnosis of major cognitive impairment, was confused, disoriented, and able to follow directions, but was unable to communicate needs. R2’s medical assessments denied any history of inappropriate, aggressive, Sundowning, or wandering behaviors. Interviews with staff and outside sources and review of admission records revealed that R1 was admitted to the facility on 10/14/2023 and occupied a shared double room with R2 within the memory care portion of the facility. Interviews with staff and outside sources and review of documents received by the Department from the facility on 10/20/2023 revealed that on 10/18/2023, R2 reported to facility staff that they were uncomfortable around R1 and that R1 had attempted to kiss and touch R2’s body. Facility staff relocated R1 to another room within the memory care the same day as R2’s statements. Review of documents received by the Department revealed that facility management followed reporting requirements and submitted an incident report and report of suspected elder abuse to the Department on 10/20/2023 as well as notified R1 and R2’s responsible parties. Interviews with staff stated that R1 would occasionally yell at or become upset with staff when they entered R1’s room to provide care, but that R1 was able to be redirected. Interviews with outside sources stated that R1’s personality could be described as “affectionate”, but those interviews did not indicate that R1 had a history of any aggressive, inappropriate, or sexual behaviors, or had a history of physically interacting with others in an affectionate manner. Review of progress notes and interviews with staff and outside sources denied any physical aggression or any additional altercations between R1 and any other residents, including R2. Interviews with outside sources revealed that R2 had complained to outside sources about R1’s behavior prior to R2’s report to the facility on 10/18/2023, but those previous complaints were not reported to facility staff. Interviews with staff and facility management did not reveal any knowledge of R1’s kissing and touching behavior prior to R2’s report on 10/18/2023. 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 ED Sheryl Johnston, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).