Allison Care Center never investigated the allegation. Administrators didn't even know about it until federal inspectors arrived in October following a complaint.
The facility's nursing home administrator said she moved Resident #4 downstairs "because it was the only open male room at the time." She placed him in the room directly facing Resident #3, who had reported the inappropriate touching.
The administrator said she discussed the room change with Resident #3 beforehand to assess her comfort level. Resident #3 declined an offer to move back upstairs. Instead, she accepted a stop sign barrier for her doorway because she could call out for help if needed.
Staff knew Resident #4 exhibited what they called "sexual behaviors." A certified nursing assistant told inspectors that Resident #4 had sexual behaviors but was "redirectable." The assistant said she had not personally observed or been told of Resident #4 inappropriately touching another resident.
But Resident #3's behavior changed dramatically after the move. The nursing assistant said Resident #3 began isolating herself in her room when Resident #4 moved downstairs. She would come out only for drinks and ate all her meals alone in her room.
Resident #3 told staff she wanted to eat meals in her room because she felt "more comfortable and safer" there.
The facility's director of nursing said staff had been made aware of Resident #4's behaviors and were advised to frequently check on him. Both the administrator and director of nursing knew that Resident #3 had previously reported that Resident #4's staring made her uncomfortable.
They said Resident #4 sometimes dissociated when he couldn't find his words, which presented as him staring at people.
Resident #4 had a history of wandering behaviors that triggered security alarms. Documentation showed he went to the front door and dining room door and pushed on the handles, setting off alarms. He also stood in other residents' doorways. Staff used stop sign barriers to redirect him, which the administrator said had been effective.
The administrator said Resident #4 was moved downstairs due to his functional status and staff concerns about him potentially bumping into other residents upstairs.
None of the facility's leadership knew about the inappropriate touching allegation until inspectors interviewed them. The nursing home administrator, director of nursing, regional clinical resource, and clinical nurse resource were interviewed together on October 14. They said they would initiate an investigation into Resident #3's allegation only after inspectors brought it to their attention.
The clinical nurse resource said no staff had reported hearing about or seeing Resident #4 inappropriately touching other residents. She said one nurse had reported that Resident #4's staring made Resident #3 uncomfortable. She said other female residents in the facility denied being inappropriately touched when asked.
A certified nursing assistant said abuse should be immediately reported to the nurse, who would then notify the director of nursing. She said she was not aware of Resident #3 having any problematic behaviors herself.
The assistant confirmed that Resident #3 moved downstairs due to her discomfort around Resident #4. She said Resident #3 went upstairs for some activities but seemed to be isolating herself otherwise.
Federal inspectors found the facility failed to protect residents from abuse and failed to investigate allegations of inappropriate contact between residents. The violation resulted in a finding of actual harm to few residents.
The inspection was conducted in response to a complaint filed against the facility. Inspectors documented that stop sign barriers and door alarms were used to manage Resident #4's wandering behaviors, but the facility had not addressed the underlying allegation that prompted Resident #3's fear and isolation.
Resident #3 continues to eat meals alone in her room, telling staff it makes her feel safer. She lives directly across the hall from the resident she accused of inappropriate touching, separated only by a stop sign barrier she can call through if she needs help.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Allison Care Center from 2025-10-14 including all violations, facility responses, and corrective action plans.