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- Licensing Specialist: Michele Sutton.
- Licensing visited facility and discussed plans to renovate the milieu area with CEO. MARS reviewed with no deficiencies noted. Licensing viewed units, isolation rooms, and grounds. Sharp metal was found on facility grounds, but staff reported residents have not been allowed to use the courtyard, grounds, or gym due to roof being replaced.
- Follow-up on self-reported incidents: CEO reported individualized behavior plans are being created for residents who exhibit frequent self-harm behaviors. CEO also plans to increase therapy and educational groups on the unit. Staff are receiving training on supervision requirements (1:1, constant LOS).
- Licensing interviewed 4 residents. Resident reported they don’t have anything to do since not being able to use the grounds or gym. Resident reported facility has locked residents’ puzzles/books in their closets, only allowing 1 item out at a time to prevent clutter; Resident stated they mostly watch TV or listen to music and “the only thing we have to do is fight, so there are a lot of fights.” Another resident stated she was upset that she was moved to a different unit instead of the peer who allegedly touched her, and stated there is “nothing different” about being on suicide and line of sight precautions and stated she is not in LOS of staff at all times.
- TA –
- 909.8 – Ensure each child is provided with opportunities for regular recreational activities and exercise; Ensure residents have group recreational activities indoors while grounds are inaccessible. CEO stated they will re-visit policy of locking recreational materials in closets.
- 901.1 – Ensure the grounds have been examined thoroughly for self-harm implements when construction is completed.
