Facility Evaluation Report

On 4/2/2025 at 3:21pm, Licensing Program Analysts (LPAs) Michael Bilger and Noel Wolf Petersen arrived unannounced to conduct a case management visit. LPA met with Administrator Christopher Walters and explained the purpose of the visit. During an investigation regarding complaint # 27-AS-20250116080733 , LPA conducted interviews with three staff members and one resident. LPA also reviewed facility file documentation including staff training records, physician’s report for resident1 (R1), care notes for R1, individual program plan (IPP) for R1, and photographs pertaining to allegation. Based on interviews and record reviews, it was determined that on 1-8-25, R1 engaged in a behavior episode involving self injurious behavior, attempting to hit staff, and property destruction which prompted staff members on duty to perform a manual restraint involving the escorting of R1 to his bed. This manual restraint consisted of staff grabbing upper arms of R1 on both sides. Interviews conducted revealed manual restraint was used due to risk of self injury and injury to staff during this behavior episode. Upon further review of training records, it was determined that staff members who exercised the manual restraint had incomplete training records and invalid certification for use of manual restraints per regulatory requirements. {Cont. on 809C}