Facility Evaluation Report

On 6-24-25 at 12:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a facility report incident. LPA met with Administrator Melissa Kim and explained the purpose of the visit. LPA conducted brief interview with Administrator and reviewed incident report. LPA also reviewed care notes for resident1 (R1). Based on record review and interview, it was revealed that on 6-14-25, facility reported an observation by facility's registered nurse that R1 engaged in self-injurious behavior resulting in 4 affected areas on R1's body. Interview and record review revealed that R1 experiences nervousness and anxiety as a result of R1's diagnosis which results in scratching self repeatedly. LPA observed care notes revealing interventions in place. Interventions continue to include use of long sleeves and pants, as well as removable mittens. Interview revealed there have been no new self-injurious behavior of R1 since the reported incident.

As a result of this case management, no citations are issued. An exit interview was conducted with Administrator and a copy of this report was provided.