Facility Evaluation Report

On 3/8/22, Licensing Program Analyst (LPA) Kevin Mknelly conducted case management visit for deficiencies found during the investigation of R1’s death. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask. Additionally, LPA was screened with temperature at the facility. Administrator arrived to assist.

81087 BUILDINGS AND GROUNDS (l) The licensee shall ensure that items which could pose a danger if readily available to clients, … are stored where inaccessible to clients. This requirement was not met based on statements by S1 That a hair straightener was found with R1 instead of being secured in the staff office. This posed an immediate risk to R1.

S1 described that found in the closet with R1 at the time of their death were a black standing lamp, a table lamp (the cord of which was used in the suicide) and hair straightener with its cord wrapped around the closet hanger bar also. S1 stated that the hair straightener should not have been left in R1’s possession rather it should have been locked in the staff office. At the time of R1’s suicide, table lamps and fans with cords were allowable. The facility has since removed fans and purchased cordless lamps.