Complaint·October 18, 2024

A resident was inappropriately touched by another resident due to neglect and lack of supervision: The allegation is that the facility neglected and lack of supervision resulting in a resident wandering to another resident's room and inappropriately touching another resident. On 11/15/2023, LPA interviewed Executive Director (ED) Marrife Duewel. ED stated on 10/24/2023 around 2:00PM, resident R1 entered resident R2's room without permission. R1 exposed self to R2. and asked for oral sex. R1 inappropriately touched R2's breast and private areas. R2 asked R1 to stop. R1 stopped and left the room. ED stated he/she went to resident R2's room immediately after he/she received the report. ED stated he/she saw R1 walked down the hallway away from R2's room. ED stated no injury noted on resident R2 after the facility staff assessed R2. ED stated after the incident, all staff were instructed to closely monitor R1's behavior and to ensure residents' safety. ED stated the facility notified R1's POA to come to the facility for a care conference on 10/24/2024, at 6:00PM. ED stated the facility notify R1's doctor the incident and to work on R1's medications. ED stated after the incident, R1's doctor prescribed new medications for R1. R1 was provided a 1:1 private caregiver and R1 goes home with R1's family after dinner or R1' family to keep R1 company at night in the facility. ED stated the facility is working with R1's family to move R1 to another facility on the coming weekend. LPA interviewed staff S1. S1 stated he/she sometimes saw R1 watching porn video in his/her room, and brought the concern to R1's care conference before this incident. S1 stated sometimes he/she saw R1 wandering in the hallway. S1 stated he/she asked caregivers to watch R1. S1 stated R1 did not have sexual incident before. S1 stated he/she knows some residents lock their door, but he/she know R2 does not lock the door. LPA interviewed staff S2. S2 stated R1 and R2 are friends in the facility. S2 stated R1 and R2 sometimes have lunch or dinner together at the same table. S2 stated R1 and R1 did not have any inappropriately behavior before. S2 stated R1 usually go home with family on weekend or on holidays. S2 stated R1's care plan should be update to have more supervision and monitoring. Continue on LIC9099-C. page 2 of 3. LPA interviewed R2. R2 stated he/she does not want R1 to get punishment. R2 stated he/she wanted to participated the scheduled facility activity. The conversation was stopped. Based on review of the law enforcement task report date 11/19/2023, the finding is R1 did enter R2's room and inappropriately touched R2's private areas. Based on review of R1's physician report dated 6/23/2022, R1 has neurocognitive impairment, and has wandering behavior. Based on review of R1's addendum to appraisal needs and service plan dated 10/02/2023, R1 had 2 incidents entering other resident's room on 10/15/23 and 10/17/2023, but the facility did not have effective action plan for it. Based on the interview with staff S1, S1 observed R1 watching porn in R1's room and was naked in R1's room, and brought S1's concern in R1's care conference meeting, but the facility did not update R1's care plan. Based on the interviews, and records reviewed, the facility lack of supervision resulting resident R1 wandering to resident R2's room and conducted inappropriately behavior and touched R2's private areas. The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED . Citations were noted today. Please see LIC9099-D. Appeal right was provided. Exit interview was conducted with ED. A copy of the report was provide to ED. Page 3 of 3.