Facility Evaluation Report

On 6/24/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management visit in regards to a secondary investigation by the Department. LPA Calandra was greeted by Zach Pilkerton, Administrator and explained the purpose of the visit.

Through the course of the Department’s investigation into the death of a resident, R1, it was determined that staff were locking resident,(R2) in their room during the evening as they were a wander risk. However, the Needs and Services plan of R2 was not formalized and signed by resident's responsible party. The facility did not properly address R2's wandering needs. This poses an immediate health, safety or personal rights risk to persons in care. A Type A citation was issued for this violation.

Based on interviews and observations, facility staff locked R2 by tying the door knob to the hand rail to prevent them from wandering around the facility. Video footage shows that another resident, R3 was also locked in their room using a device tied from the door knob to the hand rail. Residents in all residential care facilities for the elderly shall have the right to leave or depart the facility at any time. This is an immediate health, safety, or personal rights risk to persons in care. A Type A citation was issued for this violation.

The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

An exit interview was conducted. A copy of this report along with Appeal Rights was left at the facility.