Information obtained and reviewed revealed R1 was admitted to the facility on 07/29/2021. Per R1’s physician report, dated 01/18/2024, revealed that R1’s primary diagnosis is cerebrovascular disease with a secondary diagnosis of mild cognitive impairment and hyperlipidemia. Per report, R1 is identified as being confused/disoriented yet able to follow instruction and communicate their needs. The report also indicates R1 is not able to bathe, dress/groom, or take care of their toileting needs. Interviews conducted with staff revealed that they have not had any resident report or claim that they have been sexually abused by S1 or any other staff member at the facility. Additionally, during interviews conducted with R1, R1 denied any sexual abuse by S1 or anyone else in the facility. Similarly, interviews conducted with residents revealed that residents did not report any problems, complaints, or abuse by anyone working at the facility. Furthermore, per police report, dated 05/15/2024, when R1 was asked by law enforcement if they had been a victim of abuse, R1 stated they were not a victim of abuse, nor had they witnessed any of the staff abusing the other residents. Additionally, law enforcement deemed this case as “unfounded/no evidence of abuse”. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the allegation of “Sexual Abuse - staff sexually abused resident”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was also alleged that staff handled resident in a rough manner and staff caused injury to resident. It was reported that S1 was handling one resident in a rough manner while changing their diaper and another resident was observed with bruises on both their forearms.

Report Continued on LIC 9099C...

Interviews conducted with staff revealed that residents undergo a body check every morning to monitor for any cuts or bruises, ensuring that any necessary follow-up care can be provided. Staff members stated that no residents have reported any injuries caused by other staff or expressed concerns about staff being too aggressive during assistance. Additionally, staff noted that residents are vocal when they disapprove of any actions taken by staff. An interview with a family member confirmed that staff assist the residents and treat them well. Interviews with residents revealed that they have never experienced rough or inappropriate handling during assistance. Residents expressed that they are treated well by staff and reported no concerns about their living conditions at the facility. Based on interviews conducted with staff, residents, and family member, the Department does not have sufficient evidence to support the allegations of “staff handled resident in a rough manner” and “staff caused injury to resident”. Therefore, these allegations are deemed Unsubstantiated at this time.

It was also alleged that staff left residents in soiled diapers resulting in rash. It was reported that S1 leaves multiple residents ‘soaking wet’ in their diapers resulting in resident’s sustaining rashes. Interviews conducted with staff revealed that residents who are incontinent are changed every two hours, depending on their individual needs. Staff members noted that diapers are checked and changed every two hours, unless they observe the resident needing a change sooner. An interview with a family member confirmed that staff assist the resident promptly and feel that the facility is meeting the resident's needs. Interviews with residents indicated that staff frequently check on them throughout the day. Furthermore, residents reported that staff are responsive to their requests for help and expressed no concerns about their care or living conditions at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff left residents in soiled diapers resulting in rash”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was further alleged that staff disturbs resident’s sleep. It was reported that staff disturb residents sleep when waking the residents up in the mornings.

Report Continued on LIC 9099C...

Interviews conducted with staff revealed that residents are typically in their beds and ready to sleep between 8:00 p.m. and 8:30 p.m., and they wake up around 6:30 a.m. to 7:00 a.m. In the mornings, staff begin making their rounds to prepare residents to go to the dining room for breakfast. Staff stated that most residents are usually awake by the time they enter their rooms, but on occasion, a resident may request more time to get up. In such cases, staff will move on to the next resident and return later. During interviews with residents, none reported any concerns with the morning staff. Residents expressed that staff were helpful and attentive. Additionally, residents shared that they enjoyed living at the facility and reported no concerns. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff disturbs resident’s sleep”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report was reviewed and a copy issued.