It was also alleged that staff did not allow resident to have visitors at the facility. It was reported that R1’s visitor was not permitted to enter the facility to visit R1 on 12/17/2025. Record review and interviews conducted revealed that an incident occurred involving R1’s visitor and another resident. Staff reported that R1’s visitor was not denied access to the facility; however, the visitor was instructed not to walk through the facility searching for or disturbing other residents. Staff stated that visitors are permitted to visit residents at any time; however, all visitors are required to comply with the facility’s house rules while on the premises. According to the admissions agreement, page 12 under “House Rules,” it states: “Residents and their families or visitors must not be disruptive, create unsafe conditions, or be physically or verbally abusive to residents or community staff.” The incident was communicated to R1’s responsible person, who was informed that R1’s visitor would be permitted to visit provided the visit was limited to interacting with R1 only and not with other residents. The ED reported being away from the facility at the time of the incident but stated that staff communicated with them to ensure R1’s responsible person was informed.

Report Continued on LIC 9099C...

Furthermore, during resident interviews, seven out of seven residents interviewed expressed no concerns regarding visitors at the facility and reported no concerns while living at the facility. Based on the information obtained and reviewed, although the allegation may have occurred or may be valid, there is insufficient evidence to determine whether the alleged violation did or did not occur. Therefore, allegation “staff did not allow resident to have visitors at the facility” is deemed Unsubstantiated at this time.

It was further alleged that staff did not report an incident to responsible party. It was reported that R1 was not permitted to be inside Resident #2’s (R2’s) apartment and had been observed inside R2’s apartment. Records reviewed and interviews conducted revealed that on 12/16/2025, R1 was observed inside R2’s apartment; however, R2’s family members were also present in the apartment with both R1 and R2 at that time. Staff interviews indicated that the ED was not present at the facility during the incident but remained in communication with staff. Following the incident, R1’s visitor was informed that they would be permitted to enter the facility only for the purpose of visiting and interacting with R1 and not other residents. The ED directed facility staff to contact R1’s responsible party to communicate the incident involving R1, R2, and R1’s visitor. Although the ED was unable to personally contact R1’s responsible party, facility staff notified the incident to R1’s responsible party. Based on the information obtained and reviewed, although the allegation may have occurred or may be valid, there is insufficient evidence to determine whether the alleged violation did or did not occur. Therefore, allegation “staff did not report an incident to responsible party” is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.