Facility Evaluation Report

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 11:22AM. The purpose of this visit is to conduct an investigation regarding three (3) self-reported incidents that occurred on 09/11/2025 and on an unknown date approximately two (2) months ago. Upon arrival, the LPA met with staff and Executive Director (ED) Susan Weisbarth. Entrance interview conducted.

During today’s visit, LPA Barutyan conducted a brief physical plant tour to ensure there are no health and safety hazards, conducted interviews with three (3) staff members and attempted interviews with two (2) residents, and reviewed and obtained copies of pertinent records.

On 09/11/2025, the Department received an incident report and SOC341 stating that on an unknown date approximately two (2) months ago, Staff #1 (S1) pushed Resident #1 (R1) onto their toilet causing it to break. The incident was reported by Staff #2 (S2) on 09/10/2025. R1 was assessed for injuries immediately after the incident was reported and observed no injuries on R1. R1’s responsible party, the Department, the Long-Term Care Ombudsman, and Adult Protective Services were notified. The facility conducted an internal investigation during which S1 and S2 were suspended and are no longer employed at the facility. ED stated it is unknown if the incident actually occurred due to conflicts and retaliation between S1 and S2. LPA discussed mandated reporting requirements and ED stated that a formal mandated reporter training will be conducted with all staff. LPA also attempted an interview with R1.

On 09/16/2025, the Department received an incident report stating that on 09/11/2025 at 08:26AM, Staff #3 (S3) mistakenly administered Resident #2’s (R2) morning medications to R1 due to confusion of the residents’ similar room numbers. Report Continued on LIC 809-C.