Complaint Investigation Report

On 02/12/2026, it was reported that R1 stated they had been sexually assaulted by the facility’s manager approximately two weeks earlier. It was also reported that R1 stated they were not being fed well and were not receiving anything to drink. Documentation indicates that R1 has made various allegations in the past, though none involving sexual assault. Following the report, R1 refused to return to the facility and was placed on a 5150 psychiatric hold. R1 also expressed a desire for their out of state family member to pick them up.

Documentation from an outside agency shows that R1 provided conflicting statements regarding when the alleged incident occurred, stating it happened two weeks ago and also stating it occurred around Halloween of 2025. R1 has documented cognitive impairments and a history of making false statements. R1 described the alleged event as the facility manager entering their room, pushing them to the floor, and assaulting them.

R1’s family member was contacted and reported that R1 has made similar types of allegations in the past when attempting to leave the facility. R1’s family member stated they did not believe the accused staff member would commit such an act. During a subsequent conversation, R1 stated they wanted to leave the facility to live with their out of state family member. When informed this was not possible, R1 became upset and stated they would leave the facility on their own if returned there.

The staff member identified by R1 was interviewed and denied the allegation. They stated that R1 has made untrue claims previously. Staff further reported that R1 shares a room with another resident, and that the facility maintains an open door policy, which they stated would make it difficult for such an event to occur without being observed.

Another individual familiar with R1’s care was interviewed and stated they believed R1 was again attempting to leave the facility. They confirmed that R1’s roommate does not have cognitive impairments and has not reported seeing or hearing anything unusual. They also stated that R1 is provided appropriate care at the facility.

A review of R1’s facility records shows diagnoses of dementia, episodes of confusion, and a history of making false allegations. R1 also has several medical conditions, including frailty, malnutrition, mild cognitive impairment, anxiety, and depression. R1 was admitted to the facility on 03/09/2025.