Incident investigation·March 24, 2026

On March 24, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case-management visit in relation to two incidents that occurred at the facility. LPA met with Administrator, Robert Snee and explained the purpose of the visit. The Licensee reported on 3/8/26 at around 8:00pm, Resident 1 (R1) and Resident 2 (R2) were found together in a room. Both residents were observed half undressed. R1 was observed behind R2 but was not observed touching R2. R1 and R2 were immediately separated and redirected back to their rooms. There were no signs of intimacy or injuries. Licensee implemented 30 minute status checks, reminded staff to redirect and encourage both residents to join activities. All required parties were notified On 3/12/26 at around 6:40pm, the Licensee reported, R1 and R2 were found undressed and involved in an intimate act in a room. Both residents were separated and required parties were notified. Status checks were implemented for every During the visit, LPA reviewed R1 and R2's files, discussed incident with staff, and reviewed the facility's policy regarding resident relationships. According to R1 and R2's file, both residents have Alzheimer's dementia diagnosis and this was the first incident with R1 and R2 being half undressed and being intimate with each other. R1 and R2's service plan was observed to be updated to address these incidents. According to the Assistant Director of Health Services observed R1 and R2 walking around in the courtyard at around 6pm. Administrator and Assistant Director of Health Services indicated that R1 was moved to a different neighborhood and since these incidents, there has not been any new incidents and they have not been observed together. No citations are issued during the visit. Report is reviewed with Assistant Director of Health Services and a copy is provided.