Facility visited and records reviewed for 10 clients and 10 personnel.
Walkthrough conducted of Americana and Cabin 6 (visit cut short due to immediate notification of quarantine); MARs checked for 5 residents. No concerns noted.
- Census 13; Reviewed 7 medication logs. Most children were at school during the visit.
- Regs out of compliance –
- R908.8 – All evening dosages were pre-signed on the medication log. Ensure medication is only logged as dispensed and training is provided to nurses.
- R406.3 – Nurse came back to sign a noon and PRN dose while reviewing logs; Ensure medications are only logged as dispensed and training is provided to nurses.
- R406.5 – Prescription cream was left in child’s room. Corrected 11/10/21.
- TA –
- R911.6 – Hole in wall appeared to be in process of being repaired in room 9.
- Included: IOC (revised), CAP
- Multiple deficiencies noted. Plan of Correction required to be completed within 30 days.
Detective received referral from Child Abuse Hotline on 8/13/21. Sent in by fax to hotline: Juvenile 1 is 10 yo and Juvenile 2 is 11 yo. J1 reported that J2 asked him to suck his penis in exchange for toys. J1 told him no and J2 continued to bribe him with toys and to “just let him do it.” J1 reported he did suck J2s penis 2 times and J2 sucked J1s penis 5-6 times. J2 said if J1 ever told anyone that he would punch him in the face. J1 reports another time where J2 asked J1 to pull his pants down; J1 told him no and J2 pushed him against the wall and tried to stick “it” in his butt. J2 denied any penetration or contact.
- Specialist conducted building and grounds inspection; Reviewed medication logs for 8 residents. Initials were missing from the logs on the date of 8/10/21 for all 3 residents. Found multiple items of clothing during walkthrough that contained drawstrings.
- Regs out of compliance –
- R911.15.f – Ensure all shoelaces, drawstrings, and cords are removed from belongings and are not accessible to residents. This was corrected on site at the time of visit.
- R406.4.d – Ensure initials of the person giving meds are on the med log. The nurse that was on duty advised that she normally fills these out at the end of the shift. Nurse agreed to fill them out when the meds are given. The Compliance Officer advised the Nurse Manager would re-train all staff on this procedure.
- Reviewed 10 personnel records. No regs noted out of compliance.
- Specialist viewed new building that will be in use in next couple of weeks, Extension of cabin 6. Also viewed cabin 6 and Americana.
- Regs out of compliance:
- R911.15.f – One clothing item found in room with drawstring. Correction date 12/7/20.
- Regs not correctable:
- R908.8 – Meds not logged for Sunday, 12/6/20 for 2 children at 5:30am.
No regs out of compliance.
- Virtual walk thru was completed of Cabin 6, newest building on campus. Virtual walk thru was started in Americana Building but was discontinued due to technical difficulty.
- Viewed cabins 4 and 6 and all areas used by children with no safety concerns viewed at visit.
- Reviewed 10 children’s records – no deficiencies noted.
- TA: agency plans to rebuild cabins for adolescent program for the dual diagnosis program that should begin in October
- Viewed cabins 4 and 6 and all areas used by children with no safety concerns noted.
- Reviewed 10 Personnel files – social media confidentiality statement missing from all. Compliance date and date corrected listed as 06/23/19 for all.
- Viewed Americana, Cabin 4, and Cabin 6, schools, and kitchen buildings and all areas used by children with no safety concerns cited.
- TA: Discussed that I will need a copy of actions taken to address bed bug report. Date corrected 4/1/19.
- Timber Ridge Plan of Correction. Bed bugs found by staff in 1 bed.
Caller advised Resident stole a van at facility at approximately 1330 hours, Staff had Resident blocked in at front gate. Resident had taken keys from Staffs locker(not locked); Resident later got out of van and returned inside the facility. Officer advised he would send the report to the Prosecutors Office to see about relocating Resident to a more secure facility. Officer also advised Staff to keep all vehicle doors locked and all keys locked up.
Caller informed Officers that a Resident had left the facility at approximately 5:30 pm. Upon Officers arrival, Staff stated they had no one by the name the Caller gave, but stated a Resident at the facility had probably called and that last time she did this (2/15/19), she hid while several employees searched for her. Staff stated Resident had a brain tumor at a younger age and was very deviant. Staff and Officers located Resident walking on road in facility at approximately 7:15 pm; Resident stated she was fine and didn’t know why she was hiding.