Facility Evaluation Report

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a Case Management for an incident that occurred on 08/29/25 and for late reporting for incidents. LPA met with Administrator Danielle Mouw and Wellness Director Elizabeth Vasku.

LPA interviewed Administrator and Wellness Director.

Incidents that occurred on 09/6/25 and 09/07/25 were not reported until 09/19/25.

Based on interviews, the incident that occurred on 8/29/25, R1 attempted to go into R2's room, which upset R2. R1 was found with a laceration on R1's head. Staff did not witness the altercation due to staff not being in assigned area. R1 was found by the medication technician to have a laceration on R1's head. R2 was still yelling at R1 at the time the medication technician observed R1's laceration. Medication Technician redirected R1 and R2 and called 911 for R1. R1 went to the hospital and was later returned to the facility. R1 had skin adhesive applied to close the wound.

Prior to this incident R1 and R2 were having verbal altercations where staff were able to intervene.

A copy of this report was provided with appeal rights and plans of corrections.