Facility Evaluation Report

On 5-29-25 at 2:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a resident-to-resident altercation. LPA met with program director Michael Carroll and explained the purpose of the visit. LPA conducted brief interview with program director and reviewed incident report and SOC 341 forms dated 5-27-2025. Based on review of documentation and interview, it was revealed that on 5-27-2025, resident1 (R1) was approached from behind by R2 who grabbed her right shoulder and shirt, pulling her to the ground. Staff1 (S1) witnessed the incident and secured R1 to prevent a fall. R1 was assessed by staff for injuries and reported experiencing pain on her right shoulder and left hip. Staff notified 911 and R1 was transported to local hospital for further evaluation. Local law enforcement was also notified. It was further revealed that R1 received x-rays and scans with negative results for fractures. R1 has sustained bruising on her upper right arm. Needs and service plans were reviewed and determined to be updated for R1 and R2 at this time reflecting the above recent occurrence. Incident was reported within adequate time frames per regulatory requirements.

As a result of today’s case management, no citations are issued. An exit interview was conducted with program director and a copy of this report was provided.