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32 | Regarding the allegation that lack of supervision resulted in resident on resident sexual abuse: it was alleged that in June 2023, R1 reported that their spouse R2 recently sexually abused them and that R2 has been sexually abusing them for years. Per R1’s Admission Agreement, R1 and R2 moved into the same room in the facility in November 2021. Review of R1’s Physician’s Report dated November 17, 2021, and R1’s Resident Appraisal dated March 17, 2022, revealed that R1 did not have any diagnoses, was ambulatory, had no functional impairments, and was able to communicate their needs. R1’s Level of Care Assessment dated November 2, 2021, indicates R1 had no care needs and R1’s Mini-Mental State Examinations conducted on November 23, 2021, and March 17, 2022, indicate R1 had no cognitive impairment. Per R1’s Physician’s Report dated June 14, 2023, R1’s health began to decline and R1 was diagnosed with hyperthyroidism, grave’s disease, anxiety, and depression, R1 was still ambulatory, R1 was not able to communicate their needs, R1 had functional impairments relating to self-care and medication management, and R1 had complications from their recent thyroid disorder diagnosis. LPA reviewed R1’s Medical Records which indicate that in June 2023, R1 was seen by medical providers often, had multiple hospitalizations, and had multiple medication changes as their medical condition changed. LPA reviewed R1’s Care Notes which document that in June 2023, R1 was checked on regularly by staff, had contact with their family, told staff they were doing well and reported no problems, but did report medical problems and received medical care when necessary. When interviewed, AD stated that R1 had never reported any issues of abuse, staff had never suspected any abuse involving R1 and R2, and that if any abuse had been suspected, the facility would have investigated it immediately. Interviews with eight facility staff revealed that staff did not see any indications of abuse and R1 never reported any issues. LPA reviewed R2’s Physician’s Report dated June 17, 2023, which indicates R2 had a right lower extremity amputation. Per AD, R2 had an amputated leg and needed a wheelchair to move around. Per AD, R1 moved out of the facility on June 27, 2023, and R2 moved out of the facility in February 2024. R1 was interviewed by local law enforcement, did not disclose that they were sexually abused by R2, and R1 passed away in September 2023. LPA interviewed R1’s family who stated that R1’s initial report of abuse in June 2023 was the only time R1 ever reported the issue, and that the facility had no reason to suspect abuse between R1 and R2. When interviewed, R2 denied sexually abusing R1. The information obtained regarding whether R1 was abused by R2 is conflicting and the information obtained did not corroborate that the facility did not provide proper care and supervision as R1 never reported any issues to the facility and facility staff had no reason to suspect abuse between R1 and R2. |