ADHS spokesperson Steve Elliott tells 12News the agency’s policy has since changed. Now, a serious crime triggers a site survey

Link: ADHS didn’t investigate after elderly resident sexually assaulted

Author: 12News’  Bianca Buono

Published: 6:15 PM MST November 4, 2022

Updated: 8:04 PM MST November 4, 2022

FLAGSTAFF, Ariz. — Arizona’s Department of Health Services declined to investigate a Flagstaff nursing home after learning that an employee had sexually assaulted an elderly resident with memory issues.

The sexual assault happened at The Peaks in Flagstaff in January of 2021. Records show ADHS had visited The Peaks for a survey in December of 2020 and did not return until August of 2022.

ADHS spokesperson Steve Elliott told 12News in an email that the agency could have conducted an on-site survey “to examine how a facility followed other state rules and regulations” but they did not.

The employee-turned-suspect, Jonathan Chesley, was found guilty of sexual assault in October and is scheduled to be sentenced in December. He was working at The Peaks as a med tech.

RELATED: Flagstaff caregiver convicted of sexual assault

Former ADHS director critical of lack of ADHS action

“I mean, it’s outrageous,” said Will Humble.

Humble is a former ADHS director and current executive director for the Arizona Public Health Association.

Humble said he cannot comprehend the lack of state action after such an egregious crime.

“It’s outrageous that a state agency wouldn’t follow up on a verified report of a sexual assault by a staff member on a vulnerable patient in a nursing home. And they wouldn’t even show up for 18 months,” Humble said.

Chesley’s coworker walked in on him apparently sexually assaulting the elderly woman, according to a Flagstaff police report.

Chesley had previously been fired from another nursing home in the area. Records show he had told his two colleagues to take their breaks at the same time, a violation of policy, which meant he was left alone in the memory care unit.

The victim’s family filed a lawsuit against the facility alleging bad hiring and training practices and alleged the facility was negligent. Court documents show the facility settled with the family.

Humble believes they should have added ADHS to the lawsuit, too.

“This is a high-risk situation that suggests that there could be a systemic problem either with governance, hiring, staffing, training, oversight supervision, that led to a situation that would allow this to happen,” Humble said. “The only way you can tell whether that’s the case is to go out and do a field investigation.”

That investigation did not happen.

“There is no discretion. There is no judgment call. This is a high-risk situation. It’s a high-risk complaint,” Humble said.

Earlier this year, the auditor general released a bombshell report revealing a widespread problem at ADHS. After looking at records from July 2019 to April 2021, the auditor general said ADHS did not investigate complaints quickly enough, or sometimes at all, in nursing homes. These included reports of abuse and neglect.

RELATED: ADHS failing to investigate complaints at nursing homes: Auditor General report

“It’s super sad and the people of Arizona deserve better,” Humble said.

Elliott told 12 News ADHS has since changed its process. Now, whenever a serious crime is reported at any facility licensed by ADHS, the agency will respond by conducting an on-site survey “looking for any gaps in following state rules and regulations.”

Editorial Note: With the departure of Cara Christ and Colby Bower to Blue Cross Blue Shield of Arizona, ADHS has much better leadership in their licensing division (Tom Salow is leading that team now). The licensing division has suffered for many years with poor leadership, but that has now finally changed.

Let’s hope that the incoming governor recognizes that the current leadership is not responsible for the disturbing auditor general’s reports that documented a willful effort to cover up, rather than fix major problems at the department’s licensing division.

See: Auditor General’s Office Produces Scathing Review of ADHS’ Nursing Home Complaint Investigations During the Director Christ Era