Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management and met with Mary Gannon Graham (Artist Coordinator). The purpose of the case management visit was to obtain additional information regarding one self-report submitted to the Department on 3/30/26 about a suicide threat involving participant (P1).

Per incident report, on 3/30/26 around 9:30-9:40am, Artist Coordinator was notified by staff that P1 had just come to staff crying, saying they were remembering to many things from their past causing them to cry and “feel like killing myself”. Artist Coordinator held a conversation with P1, P1 reported that they were having painful memories from their past causing them to have very big emotions, they referred to it as post traumatic stress (PTSD). The facility contacted P1's responsible party to have a discussion about the situation where it was disclosed this could be a result of P1's strict keto diet and P1's responsible party agreed to contact their physician to arrange some testing to evaluate results to determine if this could be a factor of missing any nutrients that can help. Also, it was agreed that P1 will initiate therapy again to work on any emotional factors as a beneficial component to help P1 to manage their emotions. During today's visit, LPA went over incident details with Artist Coordinator and confirmed that the above details are part of the measures taken by the facility to help P1 manage their emotions to decrease the chances of maintaining suicide threats. Based on interviews conducted with facility staff, LPA was able to determine that facility addressed the incident as required per regulation, when it occurred and pertinent responsible parties were notified.

No deficiency cited during today's visit. Exit interview was conducted with Artist Coordinator and copy of this report was given.