The owners of a Duluth nursing facility are disputing "several of the findings" in a report of neglect regarding its response to alleged sexual conduct between two residents.

A report by the Minnesota Department of Health “contains details of the incident that are not accurately reported and are not consistent with witnesses’ statements,” the Benedictine Living Community of Duluth said in a statement on Tuesday.

The nonprofit was responding to an investigation completed Oct. 21 by health department special investigator Rhylee Gilb and posted online on Tuesday.

Gilb’s report, which includes no names or dates, says the incident occurred “one morning at 2:45 a.m.” at Westwood Terrace, a memory-care facility on the Benedictine Living Community campus near St. Scholastica Monastery.

It says an “unlicensed” employee entered a female resident's room to find a male resident with her. The female resident's nightgown was unbuttoned and her briefs were off. The employee reported the man was fondling the woman.

The employee reported to a licensed practical nurse who, in a written report, said she placed both residents on 15-minute checks and awaited further instructions. When the LPN woke up both residents later to talk about the incident, neither of them could recall it, Gilb reported. The LPN said she couldn’t find evidence of bruising on the female resident. But the LPN had not had sexual assault examination training, the report notes.

Both residents had dementia, and neither had any previous history of sexual behaviors, according to the report.

There was no evidence that police were contacted immediately, Gilb found. Police and family members of both residents were contacted at 11:15 a.m. the next day after a registered nurse completed an investigation.

Gilb said the police report indicated that sexual assault had taken place. It was not immediately known if criminal charges were filed.

After the incident, the male resident was given an increase in sleeping medication, Gilb reported, and a “wander alert alarm” was set for him so staff would know when he left his room. Staff was instructed to lock the female resident's door at night. However, she fell the next day and was hospitalized for a hip fracture.

In spite of the monitoring device, the male resident continued to find ways to wander at night, Gilb reported. An unlicensed employee told Gilb that the resident “still wandered into female residents’ rooms during the night naked and touched their faces,” Gilb wrote. “(The employee) stated she monitored him like crazy, but his wander alert alarm was delayed.”

In supporting the neglect finding, Gilb wrote that multiple registered nurses at Westwood failed to complete an assessment. Gilb found that no physical exams were completed of the woman for sexual assault and no treatment was given for possible sexually transmitted infections.

In its statement, the Benedictine Living Community said it is disputing some details of the report and appealing some of the findings.

It called the matter an “isolated incident between two residents.” It said that following the incident, appropriate measures were taken to safeguard the residents, and reports were made to the appropriate agencies.

“Our long tradition of quality care and commitment to the safety and security of all our residents means we took this incident seriously,” it stated.

The state hasn't responded to its appeal, according to the Benedictine Living Community statement.