Facility Evaluation Report

On 10-11-24 at 2:39pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident report received on 9/30/2024. LPA met with Administrator Karren Melegrito and explained the purpose of the visit. LPA reviewed incident report, individualized program plan (IPP), physician's report, and needs and service plan, all pertaining resident1 (R1). LPA also conducted brief interview with Administrator.

Based on interview and record review, it was determined that on 9-30-24, R1 was discovered by staff to have a 1-inch diameter bruise, blackish purple in color on left forearm. Bruise was discovered by staff during R1's shower. It was further determined that bruise was of unknown origin. First aid was applied by staff which included ice and first aid ointment. Based on interview and record review, it was revealed that R1 has an on-going history of behaviors which include self injurious behaviors such as hitting face with open hands, head banging on the floor and walls, and dropping self to the ground. Additionally, needs and services plan state R1 has history of disrobing, aggression to others, slapping with open hands, scratching, biting, and pulling hair. R1 is currently seen by Psychiatrist every 3 months, with next appointment in November 2024.

Behaviors are noted on needs and service plan and IPP along with interventions in place. LPA observed R1 to be ambulating freely, socializing with peers and staff adequately, and with no additional bruising noted at this time. Current bruise as mentioned above is yellow in color.

Based on today's case management, no citations are issued. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator.