Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by Kenya Pigg, Administrator. Facility currently has five (5) residents in care. Administrator had to leave but gave caregiver permission to sign report.

On 12/19/2025 CCL received a SOC341 self-report from the facility. SOC341 indicated that S1 had witnessed S2 handle resident (R1) in a "rough" way. SOC341 indicated that S1 was in R1's room and witnessed S2 turn R1 over so that a suppository could be inserted. S1 reports that S2 did this in a rough way.

During visit, LPA conducted interviews and reviewed documents. Per facility Admin, S2 was immediately placed on temporary leave while Elwyn conducted an internal investigation on the allegation of abuse. Per interviews conducted, the only witnesses to the alleged abuse were S1 and S2. Per review, R1 was seen by a doctor and has not had any display of adverse reactions or indication of any abuse since the alleged abuse occured. R1 has been monitored closely by facility staff since the reporting of the alleged abuse; no changes have been observed in their behavior, it remains at baseline.

On 1/5/2026 Elwyn reported the findings of their internal investigation to Admin. The findings were deemed inconclusive. Admin will forward to CCL the Elwyn investigation findings report as soon as she receives them. Admin advised LPA that because S2 is PRN staff, they have not returned to work. Admin explained that PRN staff only fill in as needed. This month the schedule is filled already, so that is why S2 is not actively on the schedule. However, because the findings were inconclusive, Elwyn will allow Admin to schedule S2 again should the need arise.

No deficiencies cited during this case management visit. Exit interview conducted with caregiver. Copy of this report was given.