Facility Evaluation Report

On 10/8/2025, Licensing Program Analyst (LPA) Murial Han conducted a Case Management visit to deliver the finding of an incident that was reported by the facility. LPA met with lead staff, Maria Teresa Manuel and LPA explained the purpose of the visit.

On August 4, 2025, the facility reported to CCL that on July 30, 2025, staff observed resident #1 (R1)'s right hand was swollen and signs of bruising after R1 returned from the day program. The facility contacted R1's day program immediately to obtain details related to the injury and interviewed staff members. Facility staff reported that there was no unusual incidences that happened prior to R1 returning from the day program.

According to the lead staff who was caring for R1 during the AM shift the day before the injury was observed, there was no pain and bruises noted. The Lead staff also stated that R1 has self injurious behavior and has a habit of bending his/her own fingers harshly, and tends to grab and crack other people's fingers, toes and feet.

LPA interviewed Staff #2 (S2) who was caring for R1 during the PM shift on the day before the injury was noted and S2 stated that there was no redness and pain observed on R1's right hand until the next day when R1 returned from the day program. S2 also stated that R1 tends to bend his/her own hands as well as others.

Based on the Appraisal/Needs and Services Plan, R1's self injurious behavior was identified and documented.

No deficiency is cited as R1 has a history of self injurious behavior and the facility sought medical attention when staff noted the injury to R1’s right hand.

This report is reviewed and discussed with the Lead Staff.