Facility Evaluation Report

Licensing Program Analyst (LPA) Darius Williams conducted an unannounced follow up Case Management visit from, 4/22/2024.

LPA conducted interviews and record reviews.

All staff involved in the restraint hold a current CPI certificate.

The facility conducted a debriefing on 4/15/2024 and documented the incident.

According to Resident 1's Individual Program Plan, there is a goal to reduce Fabricating Stories, which is defined as any instance of making verbal statements about events that are factually inaccurate(i.e. saying R1 has completed a task that R1 has not completed, saying a person did something they did not, etc).

LPA asked Resident 1 about the incident and R1 reported not remembering. LPA asked the question in other ways and received similar answers.

An exit interview was conducted and a copy of this report was provided.