Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. LPA met with General Manager (GM) Billy Mitchell.

The purpose of the visit was to follow-up on two incidents that was reported to the Department on 07/14/2025 and 07/17/2025.

On 07/14/2025, the Department was notified of alleged abuse between resident (R1) and R1’s private caregiver. It was stated that on 07/14/2025 around 1:00am, R1 pulled his/her pull cord and when staff responded R1 reported that he/she felt dizzy because R1’s private caregiver hit him/her in the head. Staff immediately contacted 911 and assessed the resident. There were no visible injuries such as bruising, redness, scratches, or marks on R1’s skin. The police arrived and R1 did not know why the police was there. The facility reported the incident to R1’s responsible party and felt R1 wasn’t in the right state of mind. Based on interview and record review, R1 has mild cognitive impairment and history of confusion upon waking up. R1’s family continued to keep services from the same private caregiver. Staff stated the resident has shown no indications of abuse. R1's physician's report, service plan and progress notes were obtained.

On 07/17/2025, the Department was notified of a medication error that occurred during the morning shift of 07/17/2025. It was reported that the MedTech in training (S1) administered resident (R2)’s medication to resident (R3). See LIC809-C for additional information.