Complaint·February 6, 2023

11:35am, reviewed and obtained copies of pertinent documents, and toured the facility with the ED at 11:55am. Investigator Ferris conducted interviews on 12/06/2022 with the ED, Wellness Director, R1, R2, Witness #1 (W1), and the reporting party; and on 01/06/2023 with facility staff. In addition, the investigator reviewed the facility file documents including documents related to R1 and R2. On 11/11/2022, the Wellness Director reported to the ED that R2 was found in R1’s room, on the floor, without pants on, but with their adult diaper on. R1 approached the Wellness Director stating they needed help as R2 was on the floor and needed assistance getting R2 up. The Wellness Director assisted R2 up, R2 had no injuries, and R2 stated they were not forced into R1’s room or forced to do anything sexually. R2 stated the visit was consensual. Per the ED, R1 has a history of strokes and slight mental impairment and R2 is diagnosed with dementia but can make their needs known and is cognizant. Both R1 and R2 live in the assisted living unit and not the memory care as they are both high functioning adults. The ED stated that R1 and R2 are frequently seen together, holding hands, kissing, and sitting together in the dining room and the front lobby. Both R1 and R2 have the independence to enter each other’s rooms and engage in activities on their own. After the incident, the ED advised R1 and R2’s resident representatives and both were unconcerned and had no objections to the relationship. According to R2’s Physician’s Report, dated 08/16/2022, the primary diagnosis is listed as late onset Alzheimer’s dementia without behavior disturbance, chronic depression, and hypertension. The report states R2 is able to follow directions and communicate needs, no wandering or inappropriate behavior. The individual service plan for R2, dated 11/14/2022, states occasional forgetfulness with reminders. Requires encouragement, reassurance, or intervention. Ambulates independently with a walker and transfers self independently. A review of R1’s Physician’s Report, dated 08/10/2022, lists the primary diagnosis as cerebrovascular accident (CVA-stroke) and motor impairment/paralysis. The report also states R1 is able to follow directions, able to communicate needs, able to care for self, and ambulatory. Report Continued on LIC 9099-C During the interview process, information obtained revealed R1 and R2 were friends and maintained a mutual consensual relationship. R2’s resident representative was aware of and supported the companionship between R1 and R2. R2 stated they had not been sexually assaulted by anyone at the facility. Witnesses interviewed denied seeing any evidence to indicate R2 was sexually assaulted when found in R1’s room and denied seeing R1 touch R2 inappropriately. In addition, witnesses denied ever hearing R2 call for help while with R1 or complain about R1’s behavior. R1 denied the allegation. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegation. Therefore, the allegation “Neglect/Lack of Supervision: Staff failed to provide supervision resulting in Resident #1 (R1) sexually assaulting Resident #2 (R2)” is deemed unsubstantiated at this time. Exit interview conducted with Community Liaison Director Ashley Villarreal. A copy of the report was provided.