Facility Evaluation Report

03/17/2026 09:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with staff Janine Pulmones. LPA spoke with licensee Serina Bortz by telephone during the visit. Today’s visit is regarding an incident that occurred on 02/03/2026 and was reported to licensing the same day.

It was reported that on 02/03/2026 8:30am Client 1 (C1) was In the. bathroom doing their morning hygiene tasks with staff. C1 had a seizure and fell, resulting in a ¼ inch long skin tear above their right eye. EMS was called and C1 was transported to the local ER where test were run It was determined that C1 was retaining urine. The skin tear did not require stitches and was glued. C1 was sent home with a catheter for the urine retention. C1 was scheduled for a follow-up appointment with their primary care physician in one week to have the catheter removed and their urine retention assessed.

During the course of the investigation, it was learned that C1 had a follow-up visit with their primary care physician, their physician removed the catheter during the visit. The urinary retention is a part of C1's aging process and is not an acute condition. During the week that C1 had the catheter staff had been trained by the facility's RN on the proper care of a urinary catheter. LPA reminded licensee that if a client has a long term catheter placement they must have a restricted health care plan for the client. The skin tear that was above C1's eye had been taped during the initial visit and has since healed.

In order to prevent this from happening again the facility has reminded staff to remain close to C1 when assisting C1 in case of fall.

No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to licensee David Bortz..