Facility Evaluation Report

On 6-13-23 at 2:03pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a resident to resident altercation which occurred on 5-19-23. LPA met with Program Director (PD) Michael Carroll and explained the purpose of the visit. LPA reviewed incident reports with PD during case management. Based on interview and record review, it was determined that R1 grabbed R2 on the arm in an aggressive manor. It was further determined that facility staff intervened and successfully separated R1 and R2 to prevent further escalation. A follow up meeting was held with facility on 6-1-23 to discuss the above event which included additional strategies put in place in regards to R1's aggression. Individualized Program Plans for R1 and R2 are updated to reflect above event including interventions. Facility reported above event to licensing department, local law enforcement, and ombudsman per regulatory requirements.

Based on this case management, no deficiencies are cited. An exit interview was conducted with program director Michael Carroll and a copy of this report was left with Michael.