An interview with Outside Source1 (OS1), an employee of OSA1, disclosed receiving an email from Outside Source2 (OS2), a staff member from Outside Source agency2 (OSA2), on March 11, 2026, with pictures of R1 with differing levels of injuries and discoloration to their arms. OS1 revealed that last time they saw R1 was on February 2, 2026, with no injuries at that time, indicating the injuries that were sustained sometime between February 2, and March 11, 2026. An interview conducted with Outside Source3, 4, and 5 (OS3, OS4, OS5), all corroborated R1 had a history of self-inflicting harm, including scratching their arms, and believed the injuries were self-inflicted, and had no concern of abuse or neglect by staff. A review of R1’s records also corroborated R1’s history of self-inflicted harm. Additionally, a review of correspondence between OS1 and OS2 stated the discoloration on R1’s arms seemed to be occurring naturally and the cause is unknown.

An interview with the facility Administrator disclosed that at R1’s admission their pre-appraisal and records received from OSA1 revealed R1 had a history of self-inflicted harm. The Administrator revealed when they assessed R1 at their prior placement (OSA3) R1 had combative behaviors and marking's on their arms. OSA3 staff disclosed were self-inflicted. Additional records revealed R1 involuntary self inflicts the abrasions to their arms are a result from being frustrated and easily bruises when being changed due to their medication (blood thinner). allegation of neglect/abuse by facility staff, it was determined unsubstantiated. An Unsubstantiated finding means the preponderance. [See LIC 811 for confidential name list].

The allegation of neglect/abuse by facility staff was determined unsubstantiated. An Unsubstantiated finding means the preponderance evidence was not met. An exit interview was conducted with the Administrator who was informed a copy of the report and appeal rights will be provided at the conclusion of the visit. Signature below confirms receipt.