Facility Evaluation Report

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

On 2/25/26 facility submitted to CCL a Special Incident Report (SIR) indicating that on 2/25/26 Elwyn Regional Director of Operations (RDO) was informed by staff (S1) that they took a photograph of the genital area of resident (R1) using their personal device. S1 reported taking the picture while conversing with RDO on an unrelated matter. S1 stated to RDO that they took the picture because they were instructed to do so at the request of a licensed nurse in order to show the amount of ointment applied to R1's genital area. The identity of the licensed nurse is known, they are a regularly scheduled staff of Elwyn Alderbrook (S3).

S1 further reported that they showed this photograph to another staff member (S2). The identity of S2 is currently unknown. S1 stated to RDO that they have since deleted the photograph from their phone. SIR stated that effective immediately, S1 has been removed from the schedule pending a formal investigation by Elwyn into this incident. Administrator advised LPA that S3 was also placed on immediate suspension. Per Administrator R1 has not expressed any behaviors as a result of the picture being taken.

Elwyn is currently conducting an investigation of the incident. Administrator will forward the investigation findings to CCL as soon as the Elwyn investigation is complete and findings have been determined. LPA and Administrator discussed staffing ratios as S1 and S3 were immediately pulled off the floor. Administrator reports removal of S1 and S3 has not created a staffing shortage as they will utilize