It is alleged that facility staff failed to provide adequate supervision when a male resident entered R1’s bedroom and engaged in inappropriate physical contact with R1 without R1’s consent. Record review revealed that both R1 and R2 are diagnosed with dementia and resided in the facility’s memory care unit at the time of the incident. During staff interviews, staff consistently reported that residents in the memory care unit are monitored approximately every two hours. Staff reported that resident bedroom doors are expected to remain locked unless a resident prefers the door to remain open. Caregiver assignment records indicated that each caregiver was assigned approximately eight (8) to ten (10) residents during their shift. Staff confirmed that R2 had been admitted to the facility approximately one week prior to the incident and required time to adjust to the new environment. Multiple staff reported that shortly after R2’s admission, R2 was observed knocking on and attempting to open other residents’ bedroom doors. Regarding R2’s behavioral history prior to admission, staff provided varying accounts of the information communicated to them. Staff generally reported being made aware of inappropriate verbal behaviors toward staff; however, the investigation did not establish that the facility had been informed of prior physical behaviors similar to the incident involving R1. On 09/12/2026, staff reported hearing R1 yelling “no” and subsequently observed R2 inside R1’s bedroom. Staff reported observing R2 making inappropriate physical contact with R1. Staff immediately intervened, removed R2 from R1’s room, and provided assistance to R1. R1 was assessed following the incident, and no immediate physical concerns were reported. Hospice, R1’s physician, and R1’s family were contacted. S1 reported that law enforcement was also contacted regarding the incident. According to S1 and S2, law enforcement was informed that the residents involved had dementia and advised that they would not respond to the facility. During resident interviews and observations, LPA separately interviewed and observed R1 and R2. LPA also attempted to interview four (4) additional residents in the memory care unit; however, due to their cognitive limitations, LPA was unable to obtain specific information regarding the incident from these residents. During the witness interview, W1 confirmed that the facility contacted R1’s family regarding the incident. W1 reported there had been no prior concerns of this nature involving R1 before the 09/12/2026 incident. Records also confirmed that a Special Incident Report (SIR) regarding the incident was submitted to Licensing on 09/12/2026. Following the incident, R2’s family, physician, and psychiatrist were informed. R2 was reassessed, and changes were made to R2’s medication, care, and supervision. Additional supervision was provided. Based on the decision of the facility and R1’s family, R1 was relocated from the memory care unit to the assisted living area to maintain separation between R1 and R2. The facility also provided in-service training to staff regarding maintaining resident bedroom doors locked in the memory care unit.