State admits ‘failure’ in assisted living center abuse investigation

KXAN's investigation into alleged sexual assaults at the Longhorn Village retirement community uncovered a state investigator who broke the law.

AUSTIN (KXAN) — Figuring out how to care for our aging loved ones is a heart-wrenching decision many of us must face at some point in our lives. You want the best environment and the best care from a quality nursing home or assisted living center. But are those entrusted to oversee care for our elderly doing all they can to protect them?

A KXAN investigation digs deep in to a case of alleged sexual abuse at Longhorn Village, a retirement community and assisted living center created by the University of Texas Alumni group, Texas Exes. During our investigation, KXAN had many questions policies and procedures for investigating abuse and neglect allegations. A state agency admitted to breaking the law and now the state is conducting a larger investigation.

The commercial on the Longhorn Village’s website shows a safe and happy place for seniors living out their golden years. But one family tells KXAN it feels the facility did not protect their mother as they expected.

“She’s very warm, very much a people person,” says the daughter of that mother.

But Alzheimer’s disease and Dementia took their toll on the Austin woman’s mother, who asked us not to reveal her face or name.

“It tears you up,” she cried. “It’s hard to watch that and know there’s nothing you can do.”

Her mother’s condition got so bad in March of 2011 a judge ruled there was “clear and convincing evidence” that she “is an incapacitated person.” The judge appointed a legal guardian since she could not make decisions for herself.

Longhorn Village seemed like the perfect place for the woman’s mother, well in to her seventies, to get the assisted care she needs.

“Oh gosh, it was great!” the daughter told KXAN. “She was 20 minutes away so I could see her and spend time with her.”

But months after entering Longhorn Village’s assisted living center, she noticed a change in her mother.

“She became more and more distraught,” she said. “She talked about wanting to move. She became more withdrawn and upset.”

Sexual Assault Allegations

In a lawsuit, The woman’s legal guardian and family claim she was sexually assaulted in February of 2012 by a male resident described in court records as a “sexual predator” on two occasions. The lawsuit, filed in February also alleges the male resident’s “sexual activities were known to the administration but nothing was done to protect his victims.”

“You believe your mother was sexually assaulted in that nursing home,” asked KXAN investigator Brian Collister. “I do,” the daughter responded. “I do believe that she was sexually assaulted.”

She is allowing us to show you her mother’s face in this picture from November of 2011, 3 months before the alleged sexual assaults.

2011
Nov. 2011
2012
Late 2012

She wants people to see what her family describes as a dramatic decline in her health in weeks and months following the alleged sexual assaults.

“I’m just heart-broken. She suffered a lot,” said the daughter.

The lawsuit(s) allege staff and management were aware of the woman’s declining health condition in the days and weeks following the alleged sexual assaults. Staff testified she became “real crazy,” “confused,” and started “acting out.” Management testified she became “increasingly agitated,” “hostile,” and “violent.” Staff and family say she had never exhibited those traits prior to the alleged assaults.

Ultimately, Longhorn Village evicted the woman after her condition and behavior quickly declined. She was taken to a hospital emergency room and would never return to Longhorn Village., but the man accused of sexually assaulting her was allowed to stay and still lives there.

Court documents show a hospital diagnosis of “acute psychosis with agitation and delusions, with acute severe deterioration of level of functioning.” After relocating to a new assisted living facility, records produced in the lawsuit show her physician assessed as her continually suffering from “dementia with unremitting psychosis.”

In court documents filed in response to the lawsuit, Longhorn Village “denies the allegations.”

Longhorn Village responds to allegations

We contacted Longhorn Village and members of its board of directors, some of whom are also on the Texas Exes board of directors, which appoints the Longhorn Village board members.

We received an email response from board members Jeff Nash who told us matters concerning Longhorn Village should be and Longhorn Village’s current Executive director, Deidre Kinsey.

Deidre Kinsey did not agree to on camera interview, but wrote, in part, in an email statement:

“We take very seriously any questions concerning the welfare of our residents and continually review our established reporting policies to ensure that any allegations of abuse or neglect are promptly identified and fully investigated.” (Click here to see the full statement.)

Leslie Cedar, CEO and Executive Director of Texas Exes responded to our request for comment saying:

Longhorn Village is an independent non-profit entity that resulted from a vision of the leaders of the Texas Exes to provide an exceptional life care retirement community for alumni and friends of the University. Today, the community is full of residents who enjoy the company of fellow graduates and other seniors who appreciate lifelong learning and being near the University.

Longhorn Village employs Life Care Services, a nationally recognized operator of retirement communities, to manage the facility, which was awarded a 5-star rating for its Health Care Center from Medicare for its health inspections, staffing and quality measures.

The allegations contained in recent court filings were investigated in 2012 by the Texas Department of Aging and Disability Services (DADS) and found to be entirely unsubstantiated. Based on this thorough, independent investigation by the state regulator, we believe the pending lawsuit against Longhorn Village is entirely without merit.

The former Director of Healthcare Services for Longhorn Village, Michael Little, was questioned during a videotaped deposition from a related lawsuit filed by a former employee who alleged she was fired from her job after voicing her concerns of the male resident’s alleged sexual activity.

“What was the obligation of Longhorn Village to its assisted living center residents?” an attorney asked. “To ensure the prevention of abuse and neglect,” Little responded.

Little denies in the deposition knowing the woman who was allegedly sexually assaulted had a court ordered guardianship and an appointed legal guardian. However, in a court hearing in that related lawsuit current Longhorn Village Executive Director, Deidre Kinsey admitted there was a copy of the court order in the alleged victim’s medical file.

Little says he never looked at the woman’s medical file.

“Didn’t you think when there was an allegation of sexual assault that the medical file should have been reviewed for the alleged victim of that assault?” the attorney asked. “Based on the information we had, we didn’t look at it as sexual assault,” Little replied. “You didn’t review the medical file after the allegations of sexual assault came up?” “No,” said Little.

Little also admits nothing was done to stop the male resident, who we are not naming since he has not been charged with a crime.

“In particular, was there any action taken to restrict (the male resident’s)  access to female patients who were suffering from dementia or some other cognitive issue?” the attorney asked. “Not for cognitive issues we were aware of,” Little responded.

“The caretaker has the same responsibility as any citizen in Texas does. And that is, if you see sexual abuse, or you suspect sexual abuse, you must report that to the state,”— Dr. Carmel Dyer.

KXAN spoke with Dr. Carmel Dyer with the Texas Elder Abuse and Mistreatment Institute. Dr. Dyer says caretakers should always know when there is a guardianship order for a person who cannot make decisions on their own.

“If a patient has been ruled incapacitated, they cannot participate in consensual sex. Period,” Dr. Dyer said.  “(Its) because they don’t have the ability to make an informed choice,” she continued.

The lawsuit filed by the guardian and family also claims Longhorn Village did not report the allegations of sexual assault to the Texas Department of Aging and Disability Services (DADS) as required by Texas law. Court records also show Longhorn Village’s Assisted Living Administration/Health Services Manual states “all reported incidents of alleged abuse are immediately investigated and reported according to state law.”

Longhorn Village admitted in court records it didn’t even tell the guardian or members of the family either. And management didn’t report it to the state. It was a nurse at Longhorn Village who eventually reported the case on her own to DADS. That nurse was Kathleen Yesian.

“We all knew her mental capacity was not one that could consent. We all knew that,” Yesian said in her videotaped deposition in her lawsuit against Longhorn Village.

Present at Yesian’s deposition was Jeff Nash, a consultant to the Longhorn Village Board of Directors and chief financial officer of Texas Exes.

After the first incident, Yesian said in her deposition, she would often check on the woman. And two weeks later she witnessed the male resident in the woman’s room again.

“I walked in to the room and I actually observed them having sex and I walked out of the room because I had been told to leave them alone. Let them do it,” Yesian claims.

Another former employee, who served as a concierge was also fired. Both sued Longhorn Village for retaliation after voicing their concerns about the male resident and the declining condition of the alleged victim.

Longhorn Village agreed to settle both of those cases but denied the allegations in its response to the lawsuits.

The state investigator for DADS said in a court hearing  he did not see the guardianship order in Yesian’s case and that it would not have mattered to him anyway. He determined what happened was consensual sex and deemed Yesian’s complaint “unsubstantiated.”

In the emailed Longhorn Village statement, Director Kinsey wrote:

“The incidents as described in a pending lawsuit were independently investigated in 2012 by the Texas Department of Aging and Disability Services (DADS). In their investigative summary report, DADS determined that, based on observation, resident interviews and record review, the allegations against Longhorn Village were unsubstantiated and no deficiencies were cited. Based on this thorough, independent investigation by the state regulator, Longhorn Village believes the pending lawsuit is entirely without merit.” (Click here to see the full statement.)

The state’s investigation

But was the DADS investigation really thorough? KXAN had many questions for DADS regarding its policies and procedures for investigating abuse and neglect allegations.

DADS initially denied our repeated requests for an interview but spokesperson Cecilia Cavuto wrote in an email statement:

“The job of DADS investigators is to find out whether a facility is in compliance with state and federal regulations. We also notify local law enforcement agencies about every allegation of abuse, neglect and exploitation that is reported to us.”

But KXAN checked with local law enforcement; the Travis County Sheriff’s Office and Austin Police Department say they have no record of any such incident reported by DADS at Longhorn Village. DADS admitted after sending the statement that it had not in fact contacted law enforcement about this case, as required by law.

The statement goes on to say:

“DADS investigations are extremely thorough, and include things such as reviews of resident medical records, reviews of facility policies and interviews with facility employees, residents and residents’ families when appropriate.”

But the family in this case says they were never contacted by DADS.

Finally, the DADS statement goes on to claim:

“It is important to note that people who reside in assisted living facilities are guaranteed the same basic rights that you and I enjoy, unless a court of law has deemed them incompetent.”

But as we already explained, the alleged sexual assault victim in this case was deemed incompetent by a court of law.

“If an investigator, an assessor, doesn’t have that medical background, I would not expect them to be able to determine whether or not someone had capacity or not,” said Dr. Dyer. “That’s why we must rely on the determination made by a judge because that took into account the medical and legal opinions,” she continued.

A spokesperson for the Texas Department of Aging and Disability Services finally agreed to an interview with KXAN hours before the story was set to air. She admitted the DADS investigator did not follow the law by failing to report the sexual assault allegation to law enforcement.

“It was a failure”

“It was a failure,” admitted DADS spokesperson Cecilia Cavuto. “It was something that needed to be done and wasn’t done,” she continued.

The state’s investigator said in a 2012 court hearing he did not even see the guardianship order and it would not have mattered to him anyway. He determined what happened was consensual sex and deemed the complaint “unsubstantiated.”

Brian Collister interviews DADS spokeswoman Cecilia Cavuto. (KXAN Photo)
Brian Collister interviews DADS spokeswoman Cecilia Cavuto. (KXAN Photo)

“In this case your investigator reviewed the medical file but was not aware that there was guardianship order. Why not?” “Correct. And we don’t know why not,” replied Cavuto. “We’re reviewing the case now to determine what if anything could’ve been done differently,” she continued.

And KXAN also discovered DADS did not follow the law requiring its investigators to report all allegations of abuse and neglect to law enforcement.

“Initially you told us this agency reported this case to law enforcement,” said Collister. “But we found that was not the case. Why didn’t it get reported to law enforcement?” asked Collister. “That’s a question we’re trying to answer at this time,” Cavuto responded. “It was not reported as it should’ve been.”

The family feels the facility and the state failed them.

“Frustrated and disappointed,” is how the daughter says she feels. “It’s just hard to imagine there’d be that kind of callous approach to someone’s care and their responsibility.”

The Texas Health and Human Services Commission confirmed to KXAN its Office of Inspector General is now investigating the case.

A spokesperson for the Texas Department of Aging and Disability Services finally agreed to an interview with KXAN today.  She admitted the DAD’S investigator did not follow the law by failing to report the sexual assault allegation to law enforcement.

“It was a failure,” admitted DADS spokeperson Cecilia Cavuto.  “It was something that needed to be done and wasn’t done,” she continued.”

The state’s investigator said in a 2012 court hearing he didn’t even see the guardianship order and it wouldn’t have mattered to him anyway.  He determined what happened was consensual sex and deemed the complaint “unsubstantiated.”

“In this case your investigator reviewed the medical file but was not aware that there was guardianship order. Why not” “Correct.  And we don’t know why not,” replied Cavuto.  “We’re reviewing the case now to determine what if anything could’ve been done differently,” she continued.

And KXAN also discovered DADS did not follow the law requiring its investigators to report all allegations of abuse and neglect to law enforcement.

“Initially you told us this agency reported this case to law enforcement,” said Collister.  “But we found that was not the case.  Why didn’t it get reported to law enforcement?” asked Collister.  “That’s a question we’re trying to answer at this time,” Cavuto responded. “It was not reported as it should’ve been.”

Claims of a “cover up”

“Do you believe Longhorn Village tried to hide this incident and cover it up from you and your family?” Brian Collister asked the daughter. “I do,” she replied. “I think they even told the nursing staff that they were not allowed to tell us what happened and as a result it was a year before we had any idea,” she claimed.

It was Yesian’s and the other former employee’s attorney that wrote to the guardian informing the family of the alleged sexual assaults 9 months later.

In her deposition, Yesian describes a meeting she says management called with her during which she claims she was told to keep quiet.

“…and I told them everything. Michael Little rolled his eyes,” claimed Yesian. “And I was told not to document it and I was told not to speak of it outside that room,” Yesian continued. “Who told you not to document it?” the attorney asked. “Michael Little,” Yesian replied.

In his deposition for Yesian’s case, Michael Little says he spoke to the daughter but claims he can’t remember if he told her about the alleged assaults.

“I don’t recall that as part of the conversation,” said Little. “Do you think you would have disclosed that?” Yesian’s attorney asked. “I don’t know,” Little responded.

Angela Brown was the manager of assisted living at Longhorn Village at the time. She confirms in her deposition that management never investigated the incidents as sexual assault.

Getting Help
If you suspect abuse or neglect of a loved one in a nursing home or assisted living facility, state law requires you to notify your local law enforcement and the Texas Department of Aging and Disability Services. DADS has 24-hour hotline you can call, 1-800-458-9858. Or you can file a report online.

“Was there ever an incident report completed about the allegations of abuse on February 11?” asked Yesian’s attorney. “No,” Brown replied. “Was there ever an initial investigation as to cause?” the attorney asked. “No,” Brown said.

Dr. Dyer says in cases like this the law is clear and caretakers and facility managers should know very well whether a resident has the capacity to consent.

“The caretaker has the same responsibility as any citizen in Texas does. And that is, if you see sexual abuse, or you suspect sexual abuse, you must report that to the state,” said Dr. Dyer.

DADS has investigated a total of three abuse/neglect complaints at Longhorn Village, none of which were found to be substantiated.

To give you further context, we obtained data showing all complaints and outcomes of DADS’ investigations of abuse and neglect at assisted living facilities in Texas. The data show from 2003 to May 14, 2014 DADS investigated 17,001 abuse/neglect complaints. Investigators determined 88 percent of those complaints were unsubstantiated while only 2,103 were substantiated. You can see all of the complaints in our online database here; search by facility name or by city.


Joe Ellis and Ben Friberg contributed to this report

blog comments powered by Disqus